KEY TOPICS IN OTOLARYNGOLOGY AND HEAD AND NECK SURGERY
SECOND EDITION

The KEY TOPICS Series
Advisors: T.M.Craft Department of Anaesthesia and Intensive Care, Royal United Hospital, Bath, UK C.S.Garrard Intensive therapy Unit, John Radcliffe Hospital, Oxford, UK P.M.Upton Department of Anaesthesia,Royal Cornwall Hospital, Treliske, Truro, UK
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KEY TOPICS IN OTOLARYNGOLOGY and Head and Neck Surgery
Second Edition

N.J.ROLAND MD, FRCS Consultant in Otolaryngology and Head and Neck Surgery, Honorary Lecturer, Liverpool University, University Hospital Aintree, Liverpool, UK R.D.R.McRAE FRCS Consultant in Otolaryngology and Head and Neck Surgery, Colchester General Hospital, Colchester, Essex, UK A.W.McCOMBE MD, FRCS Consultant in Otolaryngology and Head and Neck Surgery, Frimley Park Hospital, Surrey, UK

© BIOS Scientific Publishers Limited, 2001 First published 1995 Second Edition 2001 This edition published in the Taylor & Francis e-Library, 2005. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” All rights reserved. No part of this book may be reproduced or transmitted, in any form or by any means, without permission. A CIP catalogue record for this book is available from the British Library. ISBN 0-203-45041-8 Master e-book ISBN

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CONTENTS

Acoustic neuroma Acute suppurative otitis media Adenoids Allergic rhinitis Anaesthesia—general Anaesthesia—local Benign neck lumps Caloric tests Cervical lymphadenopathy Choanal atresia Cholesteatoma Chronic suppurative otitis media Chronic suppurative otitis media—complications Clinical assessment of hearing Clinical governance and audit Cochlear implants Congenital hearing disorders Cosmetic surgery Day case ENT surgery Epiglottitis Epistaxis Evidence based medicine Evoked response audiometry Examination of the ear Examination of the nose

1 4 7 10 13 18 22 26 28 32 34 37 41 44 48 52 58 62 66 69 72 75 78 82 85

vi

Examination of the throat External ear conditions Facial nerve palsy Facial pain and headache Foreign bodies Functional endoscopic sinus surgery Globus pharyngeus Halitosis Hearing aids HIV infection Hypopharyngeal carcinoma Impedance audiometry Intrinsic rhinitis Labyrinthitis Laryngeal carcinoma Laryngectomy Lasers in ENT Literature evaluation Mastoidectomy Medico-legal aspects of ENT surgery Menière’s disease Nasal granulomata Nasal polyps Nasal trauma Nasopharyngeal tumours Neck dissection Neck space infection Noise-induced hearing loss Non-organic hearing loss Oral cavity carcinoma

88 91 94 99 104 109 114 116 118 122 125 129 132 135 139 144 148 152 159 162 167 170 174 177 180 185 188 192 195 197

vii Oroantral fistula Oropharyngeal carcinoma Otalgia Otitis externa Otitis media with effusion (glue ear) Otoacoustic emissions Otological aspects of head injury Otorrhoea Otosclerosis Ototoxicity Paediatric airway problems Paediatric endoscopy Paediatric hearing assessment Papilloma of the larynx Perilymph fistula Pharyngeal pouch Pharyngocutaneous fistula Presbyacusis Pure tone audiogram Radiology in ENT Radiotherapy Reconstructive surgery Salivary gland diseases Salivary gland neoplasms Septal perforation Sinonasal tumours Sinusitis Sinusitis—complications Smell and taste disorders Snoring and obstructive sleep apnoea 201 203 207 210 214 217 219 222 224 229 233 237 239 242 245 247 250 253 256 259 265 268 272 275 278 280 285 291 294 297 .

viii Speech audiometry Speech therapy in head and neck surgery Speech therapy in non-malignant voice disorders Stridor and stertor Sudden hearing loss Thyroid disease—benign Thyroid disease—malignant Tinnitus Tonsil diseases Tonsillectomy Tracheostomy Tympanoplasty Tympanosclerosis Vertigo Vestibular function tests Vocal cord palsy Index 301 304 308 311 315 317 323 328 331 334 337 341 343 345 348 352 355 .

Royal Liverpool University Hospital. UK Austin Leach Consultant Anaesthetist. UK J. Colchester General Hospital. Liverpool. UK T. Birmingham. Colchester.Charters Consultant Anaesthetist. Glasgow Royal Infirmary. University Hospital Aintree.Shenoy Consultant Oncologist. UK George Browning Professor of Otolaryngology.Saeed Consultant Otolaryngologist. UK P. Royal Liverpool University Hospital. Portsmouth. Queen Elizabeth Hospital. University Hospital Aintree.Niranjan Consultant Plastic and Reconstructive Surgeon. Manchester Royal Infirmary. Liverpool.J. Essex.Watkinson Consultant Head and Neck and Thyroid Surgeon. Wirral.Lesser Consultant ENT Surgeon. University Hospital Aintree. Liverpool. Liverpool. Clatterbridge Centre for Oncology. Queen Elizabeth Medical Centre. Queens Medical Centre. University Hospital Aintree.H. UK PamYoung Senior Speech and Language Therapist. UK Michael Pringle Consultant Otolaryngologist. UK .Ramadan Consultant ENT Surgeon. UK A.S. Glasgow. UK S.R. Bebington.C. UK M. Liverpool.CONTRIBUTORS P. Queen Alexandra Hospital. Liverpool. UK Huw Lewis-Jones Consultant Radiologist. Manchester.Bradley Consultant Otolaryngologist. Nottingham. UK N.F.

ear abnormalities and deafness Commission for Health Improvement cyclophosphamide. warm-same central processing unit contralateral routing of signal cerebro-spinal fluid chronic suppurative otitis media computerized tomography delayed speech feedback digital signal processing external auditory meatus Epstein-Barr virus electrocochleography extra-capsular spread . genital anomalies. atresia choanae. heart disease.ABBREVIATIONS AA AJC ANCA ASA ASOM BAHA BDNF BERA BEHA BIPP BW c-ANCA CHARGE CHI CHOP CJD COWS CPU CROS CSF CSOM CT DSF DSP EAM EBV ECochG ECS androgenic alopecia American Joint Committee anti-neutrophil cytoplasmic antibody American Society of Anesthesiologists Acute suppurative otitis media bone-anchored hearing aid brain-derived neurotrophic factor brainstem evoked response audiometry behind the ear hearing aid bismuth iodoform paraffin paste body-worn hearing aid cytoplasmic anti-neutrophil cytoplasmic antibody colobama. oncovine (vincristine) and prednisolone Creutzfeldt Jakob disease cold-opposite. retarded growth and development. hydroxydaunorubicin.

stage and histology glial cell line-derived neurotrophic factor glossopharyngeal neuralgia Haemophilus influenzae type B hearing level holmium: YAG (laser) half-peak level half-peak level elevation human papillomavirus herpes simplex virus internal auditory meatus inner hair cell intrinsic rhinitis ‘in the canal’ ‘in the ear’ potassium titanyl phosphate (laser) multiple endocrine neoplasia magnetic resonance imaging minor salivary gland carcinoma nucleoside analogue National Confidential Enquiry into Perioperative Deaths neodymium doped-yttrium aluminium garnet (laser) neurofibromatosis type 2 non-Hodgkin’s lymphoma National Institute for Clinical Excellence noise-induced hearing loss non-nucleoside . age.xi EEMG EMLA EPS Er:YAG ESR EUA FBC FESS FNA FNAC FTA GASH GDNF GPN HIB HL Ho:YAG HPL HPLE HPV HSV IAM IHC IR ITC ITE KTP MEN MRI MSGC NARTI NCEPOD Nd-YAG NF2 NHL NICE NIHL NNRTI evoked electromyogram eutectic mixture of local anaesthetic exophthalmos producing substance erbium: YAG (laser) erythrocyte sedimentation rate examination under anaesthetic full blood count functional endoscopic sinus surgery fine needle aspiration fine needle aspiration cytology fluorescent treponemal antibody test gender.

prednisolone. etoposide. adreomycin. cyclophosphamide and bleomycin vanillylmandelic acid .xii NOHL NPC OAE ODS OHC p-ANCA PCT PE PI PHN PLF PORP PRIST pTNM PTS RAST SCC SCPL SMAS SMR SNHL SRT STIR SVR TENS TEOAE TGN TMJ TORP TPHA TSH TTS UICC URTI USS VAPEL-B VMA non-organic hearing loss nasopharyngeal carcinoma otoacoustic emission optimum discrimination score outer hair cell perinuclear anti-neutrophil cytoplasmic antibody percutaneous tracheostomy pharyngo-oesophageal protease inhibitors postherpetic neuralgia perilymph fistula partial ossicular replacement prosthesis plasma radioimmunosorbent test pathological staging permanent threshold shift radioallergosorbent test squamous cell carcinoma supracricoid partial laryngectomy superficial muscle and aponeurotic system submucosal resection sensorineural hearing loss speech reception threshold short tau inversion recovery surgical voice restoration transcutaneous electrical nerve stimulation transient evoked otoacoustic emission trigeminal neuralgia temperomandibular joint total ossicular replacement prosthesis treponema pallidum haemagglutination test thyroid stimulating hormone temporary threshold shift International Union Against Cancer upper respiratory tract infection ultrasound scan vincristine.

xiii WG WHO WNG Wegener’s granulomatosis World Health Organization White Noise Generators .

Recommended International Non-proprietary Name. List 1 . this book adheres to the following guidelines on naming of medicinal substances (rINN.NAMES OF MEDICAL SUBSTANCES In accordance with directive 92/27/EEC.rlNN to appear exclusively Former BAN amoxycillin amphetamine amylobarbitone amylobarbitone sodium beclomethasone benorylate busulphan butobarbitone carticaine cephalexin cephamandole nafate cephazolin cephradine chloral betaine chlorbutol chlormethiazole chlorathalidone cholecalciferol cholestyramine clomiphene colistin sulphomethate sodium corticotrophin cysteamine danthron rINN/new BAN amoxicillin amfetamine amobarbital amobarbital sodium beclometasone benorilate busulfan butobarbital articane cefalexin cefamandole nafate cefazolin cefradine cloral betaine chlorobutanol clomethiazole chlortalidone colecalciferol colestyramine clomifene colistimethate sodium corticotropin mercaptamine dantron rlNN epinephrine tetracaine bendroflumethiazide trihexyphenidyl chlorphenamine dicycloverine dosulepin formoterol fludroxycortide furosemide hydroxycarbamide lidocaine levomepromazine methylthoninium mitoxantrone chlormethine acenocoumarol norepinephrine pentoxyifylline procaine benzylpenicillin calcitonin (salmon) moxisylyte levothyroxine sodium alimemazine amethocaine bendrofluazide benzhexol chlorpheniramine dicyclomine dothiepin eformoterole flurandrenolone frusemide hydroxyurea lignocaine methotrimeprazine methylene blue mitozantrone mustine nicoumalone 2noradrenaline oxypentifylline procaine penicillin salcatonin thymoxamine thyroxine sodium trimeprazine . British Approved Name). BAN.Both names to appear UK Name 2adrenaline List 2 .

xv desoxymethasone dexamphetamine dibromopropamidine dienoestrol dimethicone(s) dimethyl sulphoxide doxycycline hydrochloride (hemihydrate hemiethanolate) ethancrynic acid ethamsylate ethinyloestradiol ethynodiol flumethasone flupenthixol gestronol guaiphenesin hexachlorophane hexamine hippurate hydrosyprogesterone hexanoate indomethacin lysuride methyl cysteine methylphenobarbitone oestradiol oestriol oestrone oxethazaine pentaerythritol tetranitrate phenobarbitone pipothiazine polyhexanide potassium cloazepate pramoxine prothionamide quinalbarbitone riboflavine sodium calciumedetate sodium cromoglycate desoximetasone dexamfetamine dibrompropamidine dienestrol dimeticone dimethyl sulfoxide doxycycline hyclate etacrynic acid etamsylate ethinylestradiol etynodiol flumetasone flupentixol gestonorone guaifenesin hexachlorophene methenamine hippurate hydroxyprogesterone caproate indometacin lisuride mecysteine methylphenobarbital estradiol estriol estrone oxetacaine pentaerithrityl tetranitrate phenobarbital pipotiazine polihexanide dipotassium clorazepate pramocaine protionamide secobarbital riboflavin sodium calcium edetate sodium cromoglicate sodium ironedetate sodium picosulphate sorbitan monostearate stilboestrol sulphacetamide sulphadiazine sulphadimidine sulphaguanadine sulphamethoxazole sulphasalazine sulphathiazole sulphinpyrazone tetracosactrin thiabendazole thioguanine thiopentone urofollitrophin sodium feredetate sodium picosulfate sorbitan stearate diethylstilbestrol sulfacetamide sulfadiazine sulfadimidine sulfaguanadine sulfamethoxazole sulfasalazine sulfathiazole sulfinpyrazone tetracosactide tiabendazole tioguanine thiopental urofollitropin .

The annual incidence is approximately 1 in 100 000. the cochlear nerve. Trigeminal nerve symptoms. The deafness is often associated with tinnitus (70%). Vertigo is an unusual complaint as compensation for vestibular nerve damage usually keeps pace with the slow rate of neural destruction.ACOUSTIC NEUROMA Acoustic neuroma represents 8% of all intracranial tumours and 80% of cerebellopontine angle tumours. Macroscopically the tumour appears as a firm yellowish encapsulated mass with the nerve splayed out on its surface. leading to a sudden increase in size and therefore marked symptoms such as acute vertigo or sudden deafness. Gradual and progressive unilateral deafness is the usual presenting symptom (90%). two phases can be recognized: an otological phase in which a small tumour compresses structures in the meatus. Headache. 1. numbness and paraesthesiae may all occur. Late symptoms. rarely. Discomfort and dull aching around the ear and mastoid area are probably caused by posterior fossa dura irritation due to the enlarging tumour. the facial nerve is resistant to pressure deformity and symptoms of facial weakness or hemifacial spasm are uncommon. The sexes are equally affected and. Facial pain. Clinical features Clinically. Acoustic neuromas originate at the junction of the glial and Schwann cells. Otological symptoms. whatever the time of onset and rate of progression. Pathology The medial portions of the cranial nerves are covered with glial stroma. Some patients have normal hearing (5%). and a neurological phase as the tumour expands medially into the cerebellopontine angle. This is an autosomal dominant disease due to an aberration on the long arm of chromosome 22. Sudden onset hearing loss can occur (10%). the presentation is most often between the ages of 40 and 60. Like most motor nerves. which for the vestibular nerve is usually within the internal auditory meatus. Many surgeons prefer therefore the term vestibular schwannoma to acoustic neuroma. The majority of these tumours are unilateral. 3. 2. followed by the inferior vestibular and then. 4. The commonest nerve of origin is the superior vestibular nerve. Ataxia and unsteadiness develop with . Histologically the tumour consists of packed sheaves of connective tissue cells (fasciculated) or may be composed of a disorderly loose network of cells with intercellular vacuoles and cysts (reticular pattern). and the small proportion that are bilateral (5%) are seen in multiple neurofibromatosis type 2 (NF2). Haemorrhage can occur (particularly in the reticular type). They arise from Schwann (neurolemmal) cells.

5. Cholesterol granuloma of the petrous apex. Nystagmus when present may be of the vestibular or cerebellar type. Stapedial reflex decay can be measured using impedance audiometry. The patient may have a unilateral neural hearing loss. abnormally rapid adaptation and disproportionately poor speech discrimination. the accuracy of audiometric testing is poor. used for the diagnosis of an acoustic neuroma. 7. Computerized tomography (CT) scanning with high definition and enhancement techniques will accurately diagnose and delineate most tumours. 3. alteration in conscious level and eventually coma. A unilateral or asymmetrical sensorineural hearing loss can usually be demonstrated by a pure tone audiogram. if ever. Congenital cholesteatoma. Management The ideal management is a single stage total removal of the lesion. Diplopia due to pressure on the VIth cranial nerve. Slight facial weakness may show as a delay in the blink reflex. 4. Aneurysm of the basilar or vertebral arteries. Cerebellar tumour. Hypaesthesia of the posterior external ear canal on the side of the hearing loss should raise the index of suspicion (Hitselberger sign). In the otological phase. and this gives a low-false negative rate of around 5%. Loss of the corneal reflex is an early sign of trigeminal nerve impairment. Neurological signs of the other cranial nerve palsies will eventually become apparent. However. Radiological investigations. Facial nerve impairment is usually of the sensory element and can be elicited as a lack of taste on electrogustometry or loss of lacrimation on Schirmer’s test. If the pure tone threshold hearing loss is greater than 70 dB. This is therefore the investigation of choice and is used for screening. 5. Vestibular investigations. Meningioma. Caloric responses are usually reduced in or absent from the affected side. 2. The raised CSF pressure causes failing vision due to papilloedema. The most accurate means of identifying small intracanalicular tumours is magnetic resonance imaging (MRI) with gadolinium enhancement. headache. 2. Investigations 1. Differential diagnosis of a tumour at the cerebellopontine angle 1. and hoarseness with dysphagia due to involvement of the IXth and Xth nerves is rare. with preservation of all neural function and with minimal morbidity and mortality. Terminal symptoms. but there is no abnormality in some patients with small tumours. The hearing loss is classically a neural lesion with no loudness recruitment. It demonstrates a retrocochlear lesion by an increased latency between N1 and N5 waves. Brainstem electric response audiometry has only a 3% false-negative rate. general examination will usually reveal no abnormalities. Each case must be . this ideal is not always possible.2 OTOLARYNGOLOGY progressive brain stem displacement and cerebellar involvement. Special audiometric and vestibular testing are now rarely. Later the patient may have evidence of ataxia. but should only be used when MRI is unavailable. 6. 3. Neuroma of the VIIth nerve. Audiometry. Acoustic neuromas (constitute 80% of cerebellopontine angle tumours).

346. p. Translabyrinthine approach. site and rate of growth of the lesion. London: Arnold. 1993. p. slow-growing tumours in elderly patients can be watched by carrying out CT or MRI scanning at regular intervals to gauge the rate of expansion. . with careful consideration of the age and general condition of the patient and the size. Evaluation and management of acoustic neuroma. Vertigo. Hyperfractionated stereotactic radiotherapy is considered by some to be the primary treatment modality of choice. These are popular treatments with patient self-help groups and are increasingly advocated in the USA. p. Head and Neck Surgeons. Radiosurgery or radiotherapy. Second Consensus. p. but an extended middle fossa approach can be used for larger ones. Wilson J (ed). 1993. British Association of Otolaryngologists. Acoustic schwannoma. 2. Current Opinion in Otolaryngology and Head and Neck Surgery. Conservative management Small.ACOUSTIC NEUROMA 3 assessed on its own merits. Syms C. Wright T (eds) Diseases of the Ear. Stereotactic radiosurgery (gamma knife) has been applied to the tumour margin to control growth. Ramsden RT. Kveton JF. Vestibular function tests. Acta Neurochir 1997. Costs and effects of microsurgery versus radiosurgery in treating acoustic neuroma. Van Roijen L. This gives a limited access and is usually used for small intrameatal tumours. The morbidity and mortality from both tumour growth and its operative removal increase with large tumours. Further reading Chandler CL. Microsurgery. The facial nerve can be preserved but all hearing is lost. 6th edn. 3. Hearing and the facial nerve can be preserved. Opponents to this view argue that future microsurgery may be more difficult and there is a theoretical risk of inducing malignant change. 1:53–63. 49(5): 3–16. In: Ludman H. Related topics of interest Evoked response audiometry. Middle fossa route. 1. There are three surgical approaches to the cerebellopontine angle and the choice depends on the position and size of the tumour and preoperative assessment by the otoneurologist and neurosurgeon. 535–547. 1. Tinnitus. 139:942–945. Tumours of the auditory-vestibular nerve. 78. Cerebrospinal fluid leak (often down the Eustachian tube) and meningitis are also relatively common. Effective Head and Neck Cancer Management. driving is banned for 1 year following this procedure. 3. 327. The approach tends to be used for patients with a severe sensorineural hearing loss (less than 70% speech discrimination). This is the most common approach. Removal of acoustic neuroma is associated most commonly with injury to the VIIth and VIIIth cranial nerves. Annual MRI scans show that around 60% of acoustic neuromas are not growing. 335–343. 1998. 2000. The patient’s hearing and facial nerve can be preserved. This route is feasible when there is CSF between the lateral margin of the tumour and the lateral margin of the IAM (cochlea). so this approach is also used for tumours when there is good hearing. In the UK. p. 2. British Journal of Hospital Medicine. Retrosigmoid approach. 257. 350. Radiology in ENT. Brackmann D. The main disadvantage is that there is a 15% risk of the patient developing epilepsy. Early diagnosis and removal of these tumours should therefore be the rule. A small tumour can be extracted from the meatus with negligible hazard and preservation of the facial nerve.

Streptococcus pneumoniae (40%). with or without suppuration and a fourth category namely ‘adhesive otitis media’ has been used to describe tympanosclerosis (hyaline degeneration and calcification) and adhesion formation within the tympanic cavity but should more accurately be regarded as a sequelae of otitis media. Children aged 3–7 years have the highest incidence. It may occur as a primary or a secondary infection after a viral acute non-suppurative otitis media. Pathogenic bacteria have been isolated from the nasopharynx in up to 97% of children with ASOM. Infants have a short. allowing contamination from the regurgitation of feed and when actively vomiting. the collective term for the eustachian tube. a perforated tympanic membrane or more rarely be blood-borne. adenoiditis. aditus. . A third category. Haemophilus influenzae (30%) and Branhamella (Moraxella) catarrhalis (10%) being the most commonly implicated. Causes of the latter are nasopharyngeal tumours including adenoidal hypertrophy. Acute suppurative otitis media (ASOM) Aetiology This is a bacterial disease caused by pus forming organisms. ‘specific otitis media’ has been used to describe tuberculous and syphilitic otitis media as it may present acutely or chronically. Bacteria enter the middle-ear cleft via the eustachian tube. overcrowding and malnutrition are predisposing factors. direct extension from a bacterial or secondary to a viral upper respiratory tract infection being the most common aetiological factor. chest disease and eustachian tube dysfunction. Risk factors in all age groups are recurrent or chronic rhinosinusitis.ACUTE SUPPURATIVE OTITIS MEDIA Definition Otitis media is an inflammation of part or all of the mucosa of the middle-ear cleft. Teething increases the incidence of infection. Poor sanitation and hygiene. abnormal eustachian patency. attic. wide more horizontally placed eustachian tube. tympanic cavity. cleft palate and submucous cleft palate. antrum and mastoid air cells. Classification It may be classified as acute or chronic with the suffix suppurative or nonsuppurative.

. Complications • Mucositis may progress to an osteomyelitis. red. • Extradural and subdural abscess. which may increase rapidly in intensity to become deep and throbbing. into the digastric fossa) or Bezold’s abscess (an abscess which has tracked inferiorly within the sheath of sternomastoid to form a fluctuant mass along its anterior border). Pressure necrosis of this region may cause the drumhead to rupture allowing mucopus to drain into the external ear canal. Hyperaemia rapidly follows and leashes of vessels may be seen running along or parallel to the malleus handle. Treatment 1. Children are usually fretful with a high pyrexia (> 39°C) and there may be signs of complications of ASOM. • Deafness. gleaned from bacterial sensitivity studies or lack of clinical response. Rest in a warm. The initial event after infection is mucosal oedema causing Eustachian tube occlusion and a dull tympanic membrane on examination. namely acute mastoiditis. well humidified room. Deafness progresses as suppuration occurs and both symptoms may rapidly improve if rupture of the tympanic membrane produces a mucopurulent otorrhoea. The drumhead takes on a full (i. Amoxicillin will cover the most common pathogens provided the patient is not allergic to penicillin and the organisms are not resistant. • Cerebellar. they have not been proven to be of significant value. opposite to retraction). 2. angry appearance and pus may be seen bulging postero-inferiorly. comprising signs of ASOM. 3.e. if the mastoid air cells are affected and acute petrositis should the petrous apex become involved. Soon radial vessels are visible on the drumhead and a middle ear effusion occurs. Antibiotics in an adequate dose administered until resolution. temporal lobe and perisinus abscess. a -lactamase resistant antibiotic should be chosen. • Citelli’s abscess (a subperiosteal abscess which has spread through the medial aspect of the mastoid. Oral medication is adequate in the absence of complications. Systemic and topical decongestants have a theoretical adjuvant role. the latter occurring in about 14% of cases but resistance is increasing. is a classic feature of petrositis. Conditions predisposing to ASOM should be treated on their own merit after resolution. 4. for example coamoxiclav. • Meningitis. initially described as a blocked ear and secondary to Eustachian tube dysfunction. In these circumstances.ACUTE SUPPURATIVE OTITIS MEDIA 5 Clinical features The two main symptoms are: • Pain. an ipsilateral abducent nerve palsy causing paralysis of the external rectus and pain in the distribution of the ipsilateral trigeminal nerve. Gradenigo’s syndrome. The respective cranial nerves are only separated from the petrous apex by a layer of dura so that an extradural abscess or pachymeningitis (meningitis extending to the dural layer) of this region from a generalized meningitis may also cause the combined cranial nerve signs.

Paediatric Infectious Diseases Journal. 35. • Otitic hydrocephalus. • Serous and suppurative labyrinthitis. Treatment of acute otitis media and its complications in pediatric otology. ossicles and the medial wall of the middle ear. Otolaryngologic Clinics of North America. • High-tone sensorineural hearing loss. The at-risk population (6%) are that group of patients with a congenital dehiscence of the horizontal portion of the facial nerve. Comparison of cefprozil with other antibiotic regimes in the treatment of children with acute otitis media. Sequelae of ASOM • Non-suppurative middle-ear effusion. p. p. Cholesteatoma. 13:27–34. • Adhesions between the tympanic membrane. Clinical Infectious Diseases. These persist for over 30 days in 40% of children and for over 3 months in 10%. p. . perhaps secondary to bacterial toxins migrating across the round window. Chronic suppurative otitis media. 1994. Assessing the treatment alternatives for acute otitis media. • Erosion of the ossicular chain. 1994. Chronic suppurative otitis media—complications. • Tympanic membrane perforation. • Lower motor neurone facial nerve paralysis. 1992. Related topics of interest Tympanoplasty. rarely extending in an antegrade direction to thrombose the internal jugular vein and in a retrograde direction causing a cavernous sinus thrombosis. Arguedas AG. 38. 42. 14 (suppl 2): 204–208. Stutman HR. Pichichero ME. fixing the latter.6 OTOLARYNGOLOGY • Lateral sinus thrombosis. especially following recurrent episodes of ASOM. 341. in particular the long process of the incus. 6:431–441. • Sequelae of ASOM complications. p. • Tympanosclerosis which may spread from the tympanic membrane to the ossicular chain. Further reading Haddad J Jr.

The most useful investigation is a lateral softtissue radiograph. Infants may have difficulty in feeding because they have to stop sucking intermittently to take a breath. In some children examination of the nasopharynx with a postnasal mirror will identify large adenoids. The size of the adenoids varies. Fibreoptic endoscopy is useful if tolerated by the child. but from the relative disproportion in size between the adenoids and the cavity of the nasopharynx. Pathology Inflammation due to acute viral and bacterial infections results in hyperplasia with enlargement and multiplication of the lymphoid follicles. Eustachian tube obstruction may result in earache and deafness due to recurrent bouts of acute otitis media and otitis media with effusion (glue ear). They are a normal structure with a function in the production of antibodies (IgA. The effect of the enlargement is to produce obstruction of the nasal airways and possibly obstruction of the Eustachian tubes. Symptoms are frequently wrongly attributed to enlarged adenoids. but in general they attain their maximum size between the ages of 3 and 8 years and then regress. The child with the ‘classic’ adenoid facies appearance (an open lip posture. IgG and IgM). This will give a measure of the absolute size of the adenoids and an assessment of their . The clinical features of adenoid hypertrophy are not always clear cut. snoring and hyponasal speech. The symptoms caused by hypertrophy result not from the actual size of the lymphoid mass. Nasal obstruction leads to mouth breathing. but in many children it is impossible to assess the adenoids in this way. Nasal discharge and postnasal drip or catarrh may develop as a result of secondary chronic rhinitis and sinusitis. Most of the pathological effects related to the adenoids are due to this increase in size. prominent upper incisors. some children may suffer from episodes of sleep apnoea. 2. a thin nose and a hypoplastic maxilla with a high arched palate) is rarely seen. Besides snoring. and unfortunately the parents’ history is not always reliable. a short upper lip. Clinical features 1.ADENOIDS The adenoids are a mass of lymphoid tissue found at the junction of the roof and posterior wall of the nasopharynx. but some preoperative investigations may suggest enlargement. Investigations The only reliable means of assessing the size of the adenoid is examination under general anaesthetic.

. Reactionary haemorrhage. Soft palate damage. Sleep apnoea.8 OTOLARYNGOLOGY proportion in relation to the size of the airway. • Subluxation of the atlanto-occipital joint (secondary to infection). • Persistence of symptoms. • An uncontrolled bleeding disorder. • Eustachian tube stenosis. Otitis media with effusion (glue ear). Recurrent acute otitis media. • Cleft palate. Indications for adenoidectomy Generally speaking. This is not always accurate and some children will still need an examination of the postnasal space under general anaesthetic. 2. Complications 1. Late. All children who have a bifid uvula should have a submucous cleft excluded. Immediate. Chronic rhinosinusitis. Intermediate. an adenoidectomy is only indicated if troublesome symptoms can be attributed to abnormal adenoid hypertrophy. They should never be removed in a child who has had a cleft palate repair or a congenitally short palate. Dislocation of the cervical spine. If enlarged adenoids are present they can then be curetted. The indications for adenoidectomy are as follows: • • • • • Nasal obstruction. 3. • Hypernasal speech (rhinolalia aperta). Contraindications for adenoidectomy • Recent upper respiratory tract infection. The adenoids assist in closure of the nasopharynx from the oropharynx during speech and deglutition. • • • • Anaesthetic complications. • Secondary haemorrhage.

American Journal of Otolaryngology. Tonsil diseases. Tonsillectomy. 13:259–264. 297. Assessment and treatment of adenotonsillar hypertrophy in children. 333. . This is treated in the same manner as posttonsillectomy haemorrhage. p. Advances in adenotonsillar disease. Further reading Hotaling AJ. Potsic WP. Related topics of interest Otitis media with effusion. It often improves with time and speech therapy but may be sufficiently severe to require a pharyngoplasty to correct the problem. A postnasal pack should be inserted if necessary. Follow-up and aftercare In view of the problems with accurate diagnosis and the potential long-term complications it is worthwhile reviewing adenoidectomy children in the outpatient clinic 6 months postoperatively. Some surgeons advocate removal of the upper part of the adenoid mass leaving a lower ridge of adenoid tissue against which the defective palate may continue to make contact. It is less likely to occur if children with palatal abnormalities are excluded from operation. p. The child should be returned to theatre and an attempt made to localize and diathermy the bleeding point. Silva AB. 213. 1993. 330. 1:177–184. Hypernasal speech can be a troublesome complication in some children. Snoring and obstructive sleep apnoea. 1992.ADENOIDS 9 The most serious complication is reactionary haemorrhage. p. Current Opinion in Otolaryngology and Head and Neck Surgery. p.

The Fc portion of IgE has an affinity for mast cells and basophils. The patient suffers from rhinorrhoea. but they often have nasal obstruction due to hypertrophy of the turbinates sometimes associated . It can be either seasonal (summer hayfever) or perennial (sometimes with seasonal exacerbations). Some individuals (described as atopic) will have a strong family history of allergy or a previous history of eczema or asthma. associated with itchy and watering eyes. rhinorrhoea and irritation.forinae) and animal epithelia. type 1 hypersensitivity reaction in the mucous membranes of the nasal airways. Typical allergens include pollens. house dust mite (Dermatophagoides pteronyssinus and D. This triggers a chain of events with the synthesis and release of arachidonic acid metabolites (prostaglandin D. leukotrienes and other chemotactic factors) and initiates disruption of the mast cell with degranulation of lysosomes (releasing histamine.ALLERGIC RHINITIS Allergic rhinitis is an IgE-mediated. or suppressor T cells may not be functioning correctly. The disease is very common. Long-standing cases of perennial allergy may not display all these features. Clinical features Seasonal rhinitis usually occurs any time from early summer to early autumn depending on the specific allergen. The allergen is thought to interact with two adjacent cellbound IgE antibody molecules. In normal individuals this system maintains a constant function. eosinophils infiltrate the tissues and oedema occurs. The IgE antibody is composed of an Fc and an Fab portion. This produces the typical features of vascular congestion. The effect is that capillaries become more permeable. nasal irritation and sneezing. the ground substance viscosity is reduced by enzymes such as hyaluronidase. affecting approximately 30% of the Western population. proteases and more chemotactic factors). The commonest allergens are highly soluble proteins or glycoproteins with a molecular weight in the range of 10000–40000. oedema. Aetiology Allergy is a hypersensitivity reaction of tissues to certain substances called allergens. which have receptors for the immunoglobulin on their cell membrane. In allergic patients the IgE Thelper cells appear to promote overproduction at times of exposure to the allergen. The Fab portion of IgE is free to combine with an allergen. moulds. Pathogenesis Immunoglobulin E is formed by plasma cells which are regulated by T-suppressor lymphocytes and Thelper cells. so forming a cross-link composed of IgEallergen-IgE.

they are more expensive and have no diagnostic superiority over skin tests. azelastine hydrochloride) have the advantage of minimal systemic absorption. chlorpheniramine (chlorphenamine) and adrenaline (epinephrine). Systemic absorption is negligible. Resuscitation equipment must always be available although the epidermal prick test is safe if properly performed. Crusting and bleeding are the main side-effects. and the turbinates hypertrophied. Sometimes the mucosa is red and the turbinates may have a blue hue. 3. etc. Oral antihistamines which selectively block histamine receptors. fexofenadine. do not expose the patient to the risks of the skin tests and do not rely on the use of a specific allergen. but they are more often seen in intrinsic rhinitis. etc. 2. feathers. Topical steroid sprays and drops are now considered to be the cornerstone in the treatment of rhinitis. Provocation tests. 4.ALLERGIC RHINITIS 11 with hyposmia. Examples include fluticasone. A battery of common allergens (e. The epidermal prick test and the intradermal injection test use an allergen placed on the skin of the flexor aspect of the forearm. cause minimal or no drowsiness and can be given once daily are now available (e. Nasal smears. Some patients still prefer the older antihistamines which may cause drowsiness (e. pale and swollen. An increase in eosinophils in a nasal smear indicates an allergic rhinitis but is not diagnostic. 2.g. sneezing.g. triamcinolone acetonide) should be reserved for when symptoms interfere with special events (e. If an adverse reaction occurs. If the patient is highly sensitive a widespread or even an anaphylactic reaction may result. 1.g. If the patient has an allergy to this then a wheal and flare will come up within 20 minutes. but only in short courses. moulds. astemizole. Blood tests. An eosinophilia may occur in an acute allergic reaction but is unusual in allergic rhinitis. cetirizine.g. house dust mite. Oral steroids are similarly indicated. the nasal mucosa classically appears moist. Management 1.g. Investigations There are many investigations available. but clinically the most useful are the skin tests and plasma IgE measurements.The effect can be measured objectively by rhinomanometry. These tests are more convenient. as is the chance of promoting fungal infections. Total plasma IgE levels may be measured in the plasma radioimmunosorbent test (PRIST) and IgE to specific allergens in the radioallergosorbent test (RAST). mometasone. Specific substances can be used depending on the history. Depot intramuscular injections of steroids (e. pollens. However.). 3. Intranasal antihistamine sprays (e. animal epithelia. Skin tests. a tourniquet should be placed proximally to contain it and the patient given intravenous hydrocortisone. A drop of the suspected allergen squeezed into the nose may cause symptoms (rhinorrhoea. and triamcinolone sprays. A negative control (carrier substance) and a histamine-containing solution (positive control) are used to ensure that the patient is not allergic to the carrier substance and does react in the normal fashion to histamine. Polyps may be present. loratidine). Patients with perennial rhinitis are almost invariably allergic to house-dust mite and typically have more than one allergy. Avoidance of the precipitating allergen is obviously helpful. On examination. but not always possible. school examinations).g. . 4. They are safe and effective. chlorpheniramine and triprolidine) and they should be warned of this.) are compared with the controls by the wheal they produce.

Resuscitation equipment must always be available where this therapy is performed. Baroody FM.12 OTOLARYNGOLOGY 5. they should be treated on their own merit. especially turbinate surgery when there are symptoms of nasal obstruction. deflected nasal septum or turbinate hypertrophy) or concomitant disease of the sinuses that complicate and exaggerate the symptoms of the rhinitis. Surgical treatment has a role to play other than in symptom control. Sodium cromoglycate stabilizes mast-cell membranes and therefore prevents the release of the allergic response mediators. Follow-up and aftercare Most cases of allergic rhinitis can be managed by the patient’s general practitioner. It has few side-effects.g. 6:6–17. Developments in the drug treatment of allergic rhinitis. Desensitization involves a series of injections of small amounts of the proven allergens in a purified form. Topical anticholinergic drugs (e. 7.g. in particular pollen allergy. ipratropium bromide) are useful in the treatment of patients in whom rhinorrhoea is the predominant symptom. but they show promise for the future treatment of the disease. p. 8. The main complication of this treatment is anaphylaxis. but may be effective in children and can be used for allergic conjunctivitis. Current Opinion in Otolaryngology and Head and Neck Surgery. Allergic rhinitis. Further reading Norman PS. in the hope that blocking IgG antibodies will be produced. 1985. so compliance is poor. It works in relatively few people. and for this reason its use in the UK has been discouraged. Related topics of interest Sinusitis. If the offending allergen is identified by any of the tests then the patient should be given general advice on avoidance. Intrinsic rhinitis. and in case of anaphylaxis there must be a supply of intravenous hydrocortisone. but needs to be used five to six times per day for adequate prophylaxis. Leukotriene synthesis inhibitors and receptor antagonists are not marketed for the treatment of allergic rhinitis. When there are any nasal abnormalities (e. 9. 1998. chlorpheniramine and adrenaline. 131. 75:531–545. p. It is really only of use in patients who are sensitive to only one or two allergens. 285. . Journal of Allergy and Clinical Immunology. 6.

• amnesic for the event.ANAESTHESIA—GENERAL P.g. there are also quite lengthy procedures performed on rather infirm elderly subjects. When surgery involves the airway itself. Liaison between the surgeon and anaesthetist is mandatory to anticipate and minimize critical operative events. especially bronchodilators. Routine haematological and biochemical investigations are generally limited to the following: . blood or infected material). Cardiovascular workup may require referral for left ventricular function assessment by echocardiography and exercise tests in angina patients. At the other extreme. fibreoptic and radiological imaging should involve the anaesthetist in that the appropriate measures for operative management should be planned rather than haphazard as a result of insufficient information. Nutritional correction by naso-gastric or parentral feeding may substantially improve pre-operative status of patients with swallowing difficulty. Airway assessment by clinical. Upper airway tumours are associated with longstanding cigarette consumption and patients who have already suffered for many years from chronic pulmonary and cardiovascular disease. the anaesthetist must ensure continuous patency and adequate measures to deal with any contamination (e.Charters Principles In providing general anaesthesia for ENT surgery an anaesthetist will aim to render a patient: • unresponsive to the stress of the surgical stimulus. It is important to determine pre-operatively which patients should be singled out for post-operative oximetry monitoring and the setting most appropriate for their nursing care. Obstructive sleep symptoms and a history of nocturnal apnoeas are easily overlooked on routine clerking. In these cases a thorough medical workup will assess risk and potential for improvement prior to surgery. Optimization of pulmonary function may be helped with pre-operative physiotherapy and medications review. • free from pain post-operatively. Safety during the procedure depends on the pre-morbid medical state of the patient. Pre-operative assessment Most ENT surgery can be regarded as relatively superficial procedures performed on fit young patients. effect of the anaesthetic agents used and the particular requirements of the surgery.

glycopyrolate being the best as it causes less tachycardia and does not cross the blood-brain barrier thus avoiding confusion. cancer screening especially in patients with upper airway tumours). Patients at risk of aspiration or gastric contents on induction of anaesthesia usually have a rapid induction sequence with cricoid pressure applied.14 OTOLARYNGOLOGY • FBC (females of menstrual age. and thus diffuses into air-containing spaces such as the middle ear. although patients with a compromised airway should not be sedated and appropriate reassurance may be an alternative.g. • Chest radiography (patients with cardio-respiratory symptoms. renal or hepatic impairment. isoflurane or desflurane in a mixture of nitrous oxide in oxygen. A benzodiazepine with an anti-emetic is a suitable combination. cardiac symptoms including palpitations and fainting). etomidate and propofol. or on medications such as diuretics and anti-hypertensives). prior to major operations. Steroid cover is required when patients have received steroids in the past 12 months and antibiotic prophylaxis for patients with valvular heart disease. patients over 60 years. Urea and electrolytes are mandatory when deliberate hypotension is to be part of the anaesthetic technique. a eutectic mixture of local anaesthetic: lignocaine 2. Hospitals normally have prescribed protocols for peri-operative care of diabetic subjects. It is 35 times more soluble in blood than nitrogen. These drugs are all short-acting and it is usual to continue anaesthesia by a volatile anaesthetic agent. . Pharmacological muscle paralysis is not usually mandatory for ENT surgery but can be used to facilitate tracheal intubation and to lessen the requirement for ‘deep anaesthesia’ with volatile agents alone. Induction of anaesthesia by breathing volatile anaesthetic agents remains common in paediatric practice where halothane and sevoflurane are usually preferred. They are not given if hypotension is required as the resulting tachycardia antagonizes this effect.g. enflurane. hypertension. EMLA. These guidelines are modified for the less well patient. Anaesthetic agents and technique The usual intravenous agents to induce anaesthesia are thiopentone. leading to an increase in pressure. Medical treatments should be optimised preoperatively.5% with prilocaine 2. Anticholinergics may be given as an anti-sialogogue. prior to major operations. • U&E (patients over 60 years. Nitrous oxide (N2O) This has been in use for 120 years as a general anaesthetic. Total intravenous anaesthesia’ refers to techniques where the use of inhalation agents are avoided and drugs combinations such as propofol and remifentanil (a very short acting opiate) are administered by infusion pump. Use of muscle relaxants in patients with difficult airways can lead to disaster when patients are rendered apnoeic and assisted ventilation is not possible. patients with diabetes. Premedication Premedication may be used to reduce anxiety and decrease the incidence of nausea and vomiting. after significant blood loss). e. • ECG (patients over 60 years.5%) is applied to potential venepuncture sites under an occlusive dressing. Oral sedative agents are often used in children and local anaesthetic cream (e. This is maximal after 40 min of anaesthesia and is implicated in the adverse positioning of grafts.

the use of head-up positioning to encourage venous drainage from the operative site. rarely. hypovolaemia or impaired renal or hepatic function. ischaemic heart disease. non-invasive BP and pulse oximetry). This should also apply when hypotensive anaesthesia is planned. previous cerebrovascular accident. anaemia. which releases histamine. warranted in ENT surgery. • soiling (by blood or infected material). blocks ganglia and directly reduces peripheral vascular resistance. which dilates capacitance vessels. Care of the airway The airway can be a particular problem in ENT operations and difficulties may be due to: • morphological derangement. central venous cannulation and bladder catheterization. Induced hypotension This can reduce blood loss during head and neck operations. Nitrous oxide may be excluded by substituting air or by total intravenous anaesthesia. • labetolol. Ideal postoperative haemoglobin is a compromise between a low haemoglobin (e. • trimetaphan.ANAESTHESIA—GENERAL 15 altered appearance of the tympanic membrane and postoperative nausea and vomiting. Techniques of inducing hypotension include: • • • • the prevention of anxiety-related tachycardia by good premedication. major operations will usually require invasive blood pressure monitoring. useful in preventing the reflex tachycardia seen in response to hypotension). It is contraindicated in patients with coexisting hypertension. This is however. ECG. . if ever.g. It has been suggested that packing the middle ear during surgery reduces the clinical significance of nitrous oxide-induced pressure changes. 8 mg per 100 ml) which favours blood flow through free flaps versus higher levels which may improve oxygen delivery. the avoidance of hypertension during laryngoscopy and intubation. which reduces arteriolar tone (by its alpha-blocking effect) and heart rate (by its beta-blocker effect. Large-bore intravenous access (to allow fluid correction of precipitous fall in blood pressure) and an arterial cannula for direct blood pressure monitoring are required if profound hypotension is to be induced. volatile agent-induced vasodilatation. which directly dilates arterioles and venules. It may result in cerebral or myocardial ischaemia and renal or hepatic hypoperfusion. • glyceryl trinitrate. Specific drugs used to induce hypotension include: • sodium nitroprusside. pregnancy. Blood loss measurement peroperatively often simply involves weighing swabs and measurement of the suction container. Per-operative monitoring Apart from recommended minimum standards (HR.

adaptation over time may mean that very small airways are encountered. the sedation can then be lightened and if necessary the patient is woken up. infection or haemorrhage into normal or abnormal tissue. fibrosis following radiation treatment. Tumours that are papilliferous are easier to debulk than sessile ulcers. even with mild stridor a 4-mm microlaryngoscopy tube can usually be advanced into the trachea. Tracheotomy under local anaesthesia is commonly regarded as a final fallback position but success may be difficult in an extremely restless patient who is fighting for breath. Surgery for abscesses involving part of the upper airway must always be seen in context. the Aintree intubation catheter) over a fibreoptic laryngoscope. Post-operative care needs to be in an environment where the nursing and medical staff are aware of the risk of post-operative problems and their management. . If the airway pathology is not a relative contraindication. By comparison.e. laryngeal laser surgery and tumour debulking). the use of airway devices such as the laryngeal mask airway (LMA) and cuffed oro-pharyngeal airway (COPA) may help to control the immediate airway difficulty. It should also be remembered that there is no guarantee that the trachea and in particular the subglottis will be free of pathology when there has been little time for formal investigations. External drainage under local anaesthesia may be appropriate and normally negates the risk of airway contamination. Anxiety can potentiate as well as result from respiratory difficulty and reassurance may help but even small dose of anxiolytic can induce respiratory arrest. The nature of the relevant pathology is important because chronic obstruction tends to be a relatively ‘solid’ processes (e. Patient co-operation is important when sedation is inadvisable.g. Where a patient presents acutely in a state of distress. Management of these cases does depend on the experience of the doctors concerned. Helium and oxygen mixtures may relieve symptoms as may bronchodilators and nebulised adrenalin. the endoscopist needs to have a good general idea as to where to expect to find the relevant anatomical landmarks. good radiological imaging may delineate precise morphological changes and also indicate where the abscess wall is thinnest and in danger of disruption. Antibiotics alone may resolve some situations and good drainage will usually only be effective in well organised abscess cavities. when airway obstruction has been longstanding (weeks or months). Then either can be used as a means to tracheal intubation using an exchange catheter (e. Surgical debulking may be augmented by intravenous steroids and antibiotics. Acute airway obstruction usually means that the patient presents with an airway that is not severely narrowed. In young children and adults less than 30 years of age. However. i. The surgeon and anaesthetist need to agree on a suitable end point for this surgery. sessile ulcerative tumour and granulation/deposition diseases).e. In the case of the airway worsening. i. pinhole glottis narrowing is not infrequently encountered.g. Where airway instrumentation does need to be considered. relief of symptoms should be considered while determining what investigations are feasible. Airway debulking is a particular problem for the anaesthetist. Because the view with a fibreoptic laryngoscope can be quite restricted. In all these situations the most important aspect is that the anaesthetist be as fully informed of the situation as possible pre-operatively.16 OTOLARYNGOLOGY • surgery to alter the airway itself (e. This usually proceeds shortly after the histology becomes available. acute obstruction is usually associated with a more ‘fluidic’ processes such as friable or cystic tumours. When general anaesthesia is considered necessary the anaesthetist will usually consider techniques which allow sedation to be gradually increased. This is used in patients presenting with acute airway obstruction where the immediate surgical aim is to improve the airway and acquire histology before considering formal treatment. when the airway will be adequate in the post-operative period. oedema.g. Experience will guide in the choice as to whether or not awake fibreoptic laryngoscopy should be considered. Bleeding after surgery is possible as is the risk of laryngeal oedema.

the surgery must be discontinued and ventilation stopped until the fire is extinguished with a pre-filled syringe of saline. The tracheal tube cuff is filled with saline or preformed with foam. steroids commenced and antibiotics and prolonged ventilatory support provided as necessary. 138. Related topics of interest Anaesthesia—local. The tracheal tube should then be replaced. p. 232. p. If airway fire occurs. p. a bronchoscopy performed. p. . p. 19. Laryngeal carcinoma p. the patient ventilated with 100% oxygen. wrapped in aluminium foil or laser-proof.ANAESTHESIA—GENERAL 17 Laser surgery carries a risk of an airway fire after ignition of the tracheal tube or the fresh gas mixture. Stridor and stertor. Paediatric airway problems. 124. 311. 336. Hypopharyngeal carcinoma. Tracheostomy. The tracheal tube should be flexo-metallic.

g.g. Classification There are two broad classes of LA: • esters (e. .ANAESTHESIA—LOCAL P. toxicity. diffusion. tinnitus. They vary in terms of potency. convulsions and coma. water solubility. They include: • CNS: lightheadedness. preventing it from diffusing across the axonal membrane and therefore reducing efficacy. facial twitching. Removal from the site of action tends to be by the circulation. metabolism or dilution which reduce local tissue concentration of the LA to restore nerve function. bupivacaine. larger doses can be tolerated. Complications Complications associated with the use of local anaesthesia may not be common but can be life threatening and for this reason their use should be restricted to areas where resuscitation facilities are to hand.Charters Mode of Action Local anaesthetic (LA) agents produce a reversible block in the transmission of impulses along nerve fibres. Where the circulation is poor or when vasoconstrictors (e. For ENT surgery. more of the drug remains in the ionized form. perioral paraesthesia. slurred speech. Manifestations of toxicity usually start during drug administration or very shortly afterwards. cocaine and procaine). adrenaline) are administered with the LA. • amides (e. Local anaesthetics are weak bases and the degree of ionization depends on the individual drug’s pKa and the surrounding pH. ability to penetrate mucous membranes and duration of action. toxicity most commonly results from inadvertent direct intravascular injection or rapid absorption via mucous membranes and toxicity from any concomitant vasoconstrictor is likely.g. prilocaine. 1. When applied to different sites their efficacy is influenced by these properties and the local blood supply can have implications for both duration of action and liability to toxic effects. Toxicity. The blood supply may be increased in infected tissue where the choice of local anaesthesia must be questioned. ropivacaine and levobupivacaine). lignocaine. benzocaine. This depends on the dose of the agent and speed of uptake into the circulation. At a low pH.

sprays as 4% or 10% and ointments of 2–5%. Cocaine. An amide metabolized in the liver. Prilocaine. Maximum dose: 3 mg/kg or 7 mg/kg with adrenaline. Max dose: 2 mg/ kg or 3 mg/kg with adrenaline. necessitating prolonged cardiac massage. The airway should be secured and the subject positioned horizontally. It has vasoconstrictive properties and is rapidly effective on mucous membranes. It is available in injectable form as 0. A single isomer and propyl homologue of bipivacaine (itself a racemic mixture). It is a mild vasodilator and is often given with a vasopressor. 2. . The onset of a reaction is more immediate and more severe with inadvertent intravenous administration. especially ventricular fibrillation. useful for postoperative analgesia. 6. The dosages are similar. Maximum dose 1. CPR may be required. Specific LA agents 1. generalized (and laryngeal) oedema and there may be an urticarial rash. Clinical manifestations include cardiovascular collapse. Longer acting drugs (e. Duration of action (when infiltrated): 90 min without adrenaline. Bronchodilators may be required. Metabolism to otoluidine may cause methaemoglobinaemia. If any of these symptoms occur during the injection.ANAESTHESIA—LOCAL 19 • CVS: bradycardia. The sensory block lasts longer than that with bupivacaine used in similar dosages. An amide with no vasodilating effect and lower systemic toxicity.g. IV fluids and adrenaline 1:10000 in 1 ml aliquots. adrenaline 1:200000. The single levo isomer of bupivacaine which has been shown to have less systemic toxic effects. Duration of action: 140 min. Duration of action: 30–60 min. A vasodilating amide with a long duration. Levobupivacaine. drug administration should be stopped immediately and the situation assessed. Toxic effects are usually self-limiting but fitting and cardiovascular collapse should be treated with oxygen administration. Allergic reactions. 4. Reactions are more common with esters than amides. Anyone who has had a severe reaction should be observed on a High Dependency or Intensive Care Unit to monitor cardiovascular and renal function even when immediate recovery appears complete. 5. Levo isomers of amide local anaesthetics in general tend to have lower potential for systemic toxicity than the dextro forms. At toxic levels cardiac events. may precede neurological events. Concern about toxicity has recently restricted its availability to a 10% spray used topically to facilitate nasal surgery. An ester hydrolysed by plasma cholinesterases. bronchospasm. Lignocaine. Duration of action: 240 min without adrenaline. • RS: an initial increase in respiratory rate followed by respiratory depression. Ropivacaine. Ropivacaine is said to produce less motor block for the equivalent sensory block to bupivacaine. hypoxia and respiratory arrest. 3.g. e. Continuing care (or observation and monitoring in the case of apparent recovery) in ICU or HDU is mandatory.5–2%. Bupivacaine. Cardiopulmonary collapse requires ventilation with 100% oxygen. It potentiates catecholamine activity and sensitizes the myocardium to adrenaline. 2. Antihistamines should be considered and if hypotension and bronchospasm persist steroids should also be considered. bupivacaine) can have a prolonged effect on the heart.5 mg/kg or total 100 mg in a fit adult. Maximum dose: 5 mg/kg or 7 mg/kg with adrenaline. hypotension and cardiac arrest.

in each piriform fossa for 1 min. The nasal cavities are sprayed with LA and the patient placed supine with the head extended over the end of the trolley. When using a fibreoptic bronchoscope LA is sprayed as the scope is advanced. Vasopressors are contraindicated in patients with ischaemic heart disease.5%) is a used topically in the nose and is also available combined with lignocaine. A 2-ml volume of 5% cocaine is applied to each nasal cavity using a specially angulated cannula. Additional anaesthesia may be supplied by anterior ethmoidal or maxillary nerve blocks or by infiltration of the columella. Ear. two wool applicators soaked in LA are applied. . • Krause’s method—a swab soaked in 4% lignocaine is held. Phenylephrine (0. hypertension or thyrotoxicosis and in those on monoamine oxidase inhibitors.20 OTOLARYNGOLOGY Vasoconstrictors Combined with a LA agent these reduce the risk of systemic toxicity and intraoperative bleeding and prolong the duration of action. (b) Nasal pack. or using a benzocaine lozenge. Local anaesthetic uses in ENT surgery 1. sensitises the myocardium to adrenaline and concomitant use is better avoided. a volatile anaesthetic agent. 3. LA is used for direct laryngoscopy or awake intubation. Alternatively. Nose. Pharynx. A 2-ml volume of 4% lignocaine is injected via the cricothyroid ligament after aspiration of air to confirm needle placement. An initial cricothyroid injection can reduce coughing when the trachea is incised. one to the region of the sphenopalatine foramen and the other to the anterior end of the cribriform plate. larynx and trachea. Halothane. (b) Cricothyroid injection. 2. Anaesthesia for tracheostomy is by field infiltration with progressive supplementation. LA used on its own or combined with general anaesthesia. (a) Modified Moffet’s technique. Infiltration may be supplemented by: (a) Auriculotemporal nerve block—2 ml of lignocaine is injected anterior to the meatus. A small intravenous cannula with the needle removed avoids needle stick injury to the posterior tracheal wall during the coughing on injection. by Krause’s forceps. The oropharynx is anaesthetized by spraying or nebulizing 4% lignocaine. After removal of the pack. the following blocks may be used: (a) Superior laryngeal nerve. • Percutaneous—2 ml of LA is injected where the nerve divides at the greater cornu of the hyoid. Vasopressors are contraindicated in sites supplied by end arteries. After 10 min the nose is pinched and any remaining solution removed. After applying LA to the nasal cavity. ribbon gauze soaked in LA is packed into the nose and left for 10 min.

ANAESTHESIA—LOCAL 21 (b) Greater auricular nerve block—2 ml of lignocaine is injected 2 cm both anterior and posterior to the tip of the mastoid. . Related topic of interest Anaesthesia—general. 14. p.

2. nails or thyroid tissue.BENIGN NECK LUMPS Classification (a) Congenital (defined as present at birth): lymphangiomas. Epidermoid cysts. cavernous (dilated lymphatic spaces). . True dermoids lined with squamous epithelium and all other normal skin appendages. cheek and floor of the mouth. (e) Salivary gland tumours. The last four groups above are discussed as separate topics elsewhere in the book. endodermal and mesodermal elements. There are three types: 1. and cystic hygroma (cysts of varying sizes). (g) Neck space infection. Cystic hygromas usually arise in the lower neck. for example teeth. (f) Reactive neck lymphadenopathy. Injection of sclerosants and radiotherapy have been suggested but are not recommended. Dermoid cysts These are midline swellings that do not move with swallowing or tongue protrusion. (d) Thyroid swellings. (b) Developmental: branchial cysts. Teratoid cysts are lined by respiratory or squamous epithelium and contain ectodermal. Congenital Lymphangiomas There are three types of lymphangioma: simple (thin walled channels). lined only with squamous epithelium. Simple and cavernous lesions arise principally in the lips. (c) Tumours of the parapharyngeal space. 3. dermoids. thyroglossal cysts. Treatment is by surgical excision. laryngoceles. pharyngeal pouches. developmental and parapharyngeal-space lumps. This chapter describes congenital.

perhaps because of a wider than usual true cord to false cord distance (wide neck) or because the false cord is compressed against the saccule to create a one-way valve. They move with swallowing and tongue protrusion as they are ultimately attached on their deep aspect to the larynx. The tract may climb anterior or posterior to the body of the hyoid to the tongue base. are recommended. This is the current consensus view. coughing. Developmental Branchial cysts Four theories regarding aetiology have been proposed: 1. They are remnants of the duct connecting the thymus to the third pharyngeal pouch. They may contain elements of thyroid tissue and may even be the sole source of functioning thyroid tissue. if wall remnants are left. occurring between the body of the hyoid bone and the cricoid cartilage. They are remnants of the cervical sinus. Ninety per cent of thryoglossal cysts are midline and 9% left-sided. 3. although an ultrasound scan is less invasive and will allow confirmation of whether there is a normal gland present. if the child allows. a fistula. expanding internally to present in the vallecula or externally through the thyrohyoid membrane. Following this procedure the recurrence rate varies from 2% to 8%. Thyroglossal cysts should not be incised and drained as this may cause an ugly sinus which is difficult to excise in toto and in continuity with the deflated cyst. pain and tenderness. They arise from remnants of the first pharyngeal pouch. Branchial cysts are lined by stratified squamous epithelium and contain lymphoid tissue in their wall. They arise from the laryngeal saccule. They usually present in young adults. 4. 60% on the left and 60% in males. 80% in men with a mean age of 55. A long course of antibiotics and repeat aspiration of the cyst. In those in whom the saccule expands. Most arise along the line of the deep cervical lymph nodes deep to the anterior border of sternomastoid at the junction of its upper third and lower two thirds. Laryngocele Only about 30 occur each year in the UK. In most subjects raising the intralaryngeal pressure causes no expansion of the saccule. The body of the hyoid and preferably a wedge of tongue base should therefore be included in the excision of the cyst (Sistrunk’s Procedure). Diagnosis is by clinical examination and from fine needle aspiration biopsy. If the hyoid body is not removed the recurrence rate rises to 85%. In a patient over the age of 40 years a metastatic node must be excluded. sneezing or . 2. Infection causes the rapid onset of diffuse swelling. A quarter of branchial cysts become infected and should be managed similarly to an infected thyroglossal cyst. Most occur in childhood (mean age 4 years). They arise from elements of squamous epithelium within a lymph node. Excision should only be attempted when all inflammation has settled to minimize the risk of rupturing the cyst wall.BENIGN NECK LUMPS 23 Thyroglossal cysts These are cysts along the tract of the obliterated thyroglossal duct. which may lead to a recurrence or. Many experts therefore recommend a 99mTc or radio iodine (131I) uptake scan prior to excision.

Plain anteroposterior and lateral neck radiographs may show an air-filled sac. but paralysis is unusual. The cells are not functionally active. the sympathicoblasts to ganglioneuromas and chemodectomas (carotid body tumours. However. An intermittent neck swelling is the usual presentation. Parotid deep lobe tumours. They are occasionally associated with a ventricular carcinoma. when the tonsil will be displaced towards the midline. Parotid tumours are the commonest and are discussed elsewhere (see Related topics). . Occasional reports of metastases in the literature may be confusing a chemodectoma with a large-cell neuroendocrine carcinoma. Parapharyngeal tumours expand either medially. occurs in chemodectomas of these three sites. giving rise to reduced function. and glossopharyngeal. Their expansion may compress the involved nerve. Schwann cells give rise to neurofibromas and schwannomas. sometimes causing weakness or paralysis of the involved nerve. perhaps with hoarseness. syncope. glomus vagale and glomus jugulare tumours). Tumours of the parapharyngeal space This space is described in Neck space infection (p. Carotid body tumours may be pulsatile with an audible bruit. It is therefore important to exclude a metastatic node as a cause of the swelling. or laterally to present in the upper deep cervical region. accessory and hypoglossal nerve palsies may arise if the tumour expands at the skull base. Chemodectomas may occur rarely at other sites. particularly the larynx. 188).24 OTOLARYNGOLOGY trumpet playing may fully develop the laryngocele. vagal. the common tumours are: • • • • Lipomas. which includes the upper half of thyroid cartilage on the side of the laryngocele so that its neck can be ligated. Neurogenous tumours develop from neural crest cells which have differentiated into Schwann cells or sympathicoblasts. is referred to as a glomus jugulare. which. Vagal paragangliomas arise from paraganglionic tissue within the perineurium of the vagus. so the safest treatment is excision. Carotid aneurysm. Patients present with a slow-growing painless lump in the neck or a mass pushing the tonsil medially. (a) Neurofibromas arise from endoneural fibrous connective tissue and are composed of a mass of spindle cells which can entwine nerve fibres. Neurogenous tumours. It is usually impalpable but may become both visible and palpable on performing the Valsalva manoeuvre. these carotid body tumours are rare except in high-altitude population centres such as Mexico City. (b) Schwannomas are benign tumours of the neurolemma or sheath of Schwann and so tend to be encapsulated. On the medial side of the carotid bulb are found highly vascular tumours arising from the carotid body cells. the glomus vagale tumour. Laryngoceles may obstruct the larynx. if ever. In the parapharyngeal space a painless neck mass is usually the only sign. although with the vagal nerve paragangliomas pulsating. (c) Chemodectomas arise from paraganglionic tissue at three common sites in the neck. Indirect laryngoscopy may reveal fullness of the ipsilateral false cord. cough or pain. if it involves the ganglion nodosum just below the jugular foramen. Malignant change rarely. tinnitus.

274. is indicated. trauma or infection. risk of stroke from surgery. 2000. p. Effective Head and Neck Cancer Management. Wilson J (ed). Recent publications have suggested that carotid body tumours may be radiosensitive and radiotherapy may be indicated either as adjuvant treatment or in those unfit or unwilling to have surgery. all of which must be known prior to surgery. Under no circumstance should either a Tru-cut biopsy or a biopsy from within the mouth be attempted because the vascularity of a carotid body tumour may cause a rapidly expanding parapharyngeal haematoma which might occlude the oropharyngeal airway. Vocal cord palsy. transparotid or transmandibular route. For these reasons. if necessary under CT guidance. 1990. 159:389–393. . but definite. although symptoms gradually settle. its principal feeding vessels and the presence of a cross-circulation. may allow a definite diagnosis to be made. If expanding or causing transient ischaemic attacks. The parapharyngeal space can be approached by either a transcervical. p. There is also a small. Jackson CG.BENIGN NECK LUMPS 25 A carotid aneurysm may be caused by atheroma. Head and Neck Surgeons. p. Recher G et al. Investigations An MRI scan will delineate the position and assess the size and vascularity of the mass. except those who had a lipoma. If a carotid body tumour is suspected a digital subtraction angiogram will allow precise definition of the tumour circulation. A significant proportion of young patients will refuse surgery if presented with all the facts. Further reading Ferlito A. 354. Assessment and treatment of neurogenic and non-neurogenic tumours of the parapharyngeal space. Salivary gland neoplasms. Second Consensus. Head and Neck Surgery. it can be resected and replaced with a reversed saphenous vein graft. A fine-needle aspiration biopsy. 188. Salivary gland diseases. 7:32–43. Treatment The mass will as a rule continue to expand so that symptoms may progress. American Journal of Surgery. Pesavento G. The vagus and the hypoglossal nerves are at risk of injury. Glossopharyngeal and vagal nerve injury may give rise to aspiration and a hoarse voice. p. British Association of Otolaryngologists. 1984. Harris PF. 271. Glasscock ME et al Diagnosis and management of paragangliomas of the skull base. especially if an experienced speech therapist is involved in rehabilitation. A tissue diagnosis may not be possible. A vocal cord palsy is treated as discussed elsewhere (see Related topics of interest). Related topics of interest Neck space infection. surgery is the treatment of choice for parapharyngeal tumours. Follow-up and aftercare Review of all parapharyngeal mass patients postoperatively for 5 years.

kept at these temperatures in two heated tanks about 1 metre above the test couch. This fluid movement leads to stimulation of the stereocilia and consequent nystagmus and vertigo. The inertia of the endolymphatic fluid means that there is a relative difference in the velocity of the canal and the fluid with head movements. cold water (30°C) is run into the left ear. Within the ampulla exists a saddle-shaped crista upon which sits a gelatinous cupula. Procedure The classic bithermal calorics utilize water at 30 and 44°C. Caloric testing was further refined in 1942 by Fitzgerald and Hallpike when they described a standardized bithermal caloric test which remains an essential vestibular investigation to this day. This results in fluid being forced through the gap between crista and cupula and a deflection of the stereocilia which causes either an increase or decrease in the resting tonic discharge depending on the direction of deflection. via a siphon tube and 14G cannula. After checking that the external canals are clear of wax and debris and that the tympanic membranes are intact. As the three canals are mutually at right angles. Positional alterations and the presence of a caloric response in microgravity have led to suggestions that a direct thermal effect on the sensory organs may account for as much as one-third of the response.CALORIC TESTS Physiology The semicircular canals are paired sensory structures responsible for the detection of angular acceleration. the whole membranous canal is filled with endolymph. He postulated that altering the temperature of the endolymph sets up thermally induced convection currents. complex three-dimensional information is provided. The two labyrinths work in conjunction so that an increase in neural signals from one canal will be associated with a decreased discharge rate from the corresponding canal on the opposite side. Background The caloric response can be used to test the integrity of this system and was first described by Robert Barany in 1906 and for which he was awarded a Nobel prize in 1914. A stopwatch is used to time the period from the . The patient reclines on the couch at 30° above the horizontal so as to bring the lateral semicircular canal into the vertical position. It has become apparent in recent years that thermal convection currents are not the only component in the caloric response. for 40 seconds. Each canal possesses a dilation at one end called the ampulla. although this in no way reduces the value of the test.

horizontal canal or vestibular nerve on that side). warm-same).g. 1. It may be localizing with some peripheral lesions. p. multiple sclerosis or lateral brainstem infarction).CALORIC TESTS 27 start of this manoeuvre to the point at which the nystagmus stops with the patient fixating on a point on the ceiling. Comparison of caloric nystagmus by observation of duration and by electronystagmographic measurement of slow-phase velocity. 1990. and in patients with perforated eardrums air may be used to supply the thermal stimulus. This is easily remembered by the mnemonic COWS (cold-opposite. the direction of the nystagmus is described by its fast phase. p. • A directional preponderance denotes a non-specific enhancement of nystagmus in one particular direction. Clinical indications Caloric testing forms the cornerstone of investigation for any vestibular pathology and is therefore useful in all patients with vertigo. Although MRI scans are now the investigation of choice for an acoustic neuroma. 134. 29:107–116. p. 346. Further reading Luxon LM. Related topics of interest Acoustic neuroma. It suggests pathology. Labrynthitis. . caloric tests may still be of some value. Exceptions to this include patients with lesions at the vestibular nerve-root entry-zone of the brainstem (e. • Unilateral canal paresis denotes that the response of one side to hot and cold stimuli is reduced or absent compared with the opposite side. when directional preponderance is usually directed away from the diseased ear. This procedure is repeated for the right ear and then for both ears with the warm water (44°C). Cold stimulation leads to nystagmus with the fast phase to the opposite side. Cold tap water can be used as a very basic single temperature screening test. as the tumour usually arises from the superior vestibular nerve and leads to an ipsilateral canal paresis. based on the recorded times for each part of the standard caloric test.g. but is usually non-localizing (may arise from any part of the peripheral or central vestibular system). British Journal of Audiology. Further refinements can be added by the use of Frenzel’s glasses to remove optic fixation or measuring the nystagmus electrically (electronystagmography). Controversies on the caloric response. to predict the degree of vestibular activity. p. The most common abnormalities found are canal paresis or directional preponderance (or a combination of the two). This finding invariably implies a lesion of the peripheral vestibular system (e. while warm stimulation leads to nystagmus with the fast phase to the same side. in which there is central pathology and also a canal paresis. Various formulae exist. 109:162–167. Acta Otolaryngologica. 350. A number of variations on this basic theme exist. By the nature of the test a canal paresis or directional preponderance must be greater than 20–25% to be significant. Vestibular function tests. Vertigo. Interpretation By definition. 1995. Stahle J.

2. haematogenous). very rarely. Fine-needle aspiration (FNA) cytology is probably the single most useful diagnostic procedure if a neoplastic lymph node is suspected. In a patient with positive nodal disease. the posterior belly of digastric and the body of the mandible. Neoplastic (primary arising from neck structures. tuberculosis. the usual expected survival rate for any specific primary tumour is reduced by one half. 4. branchial and dermoid cysts). 23). examination including endoscopy. The diagnosis is from the history. actinomycosis. Congenital or developmental (thyroglossal. Falsenegative and. false-positive results can occur with FNA. The scans can also reveal the integrity or involvement of the vasculature by a metastatic lymph node. In this topic a simple differential of these diseases is presented. Differential diagnosis Most cervical masses fall into one of four broad groups: 1. Infectious (tonsillitis. Therefore. Cervical node status is one of the most important prognostic factors in the head and neck cancer patient. the hyoid bone. metastatic secondaries. HIV). A primary carcinoma arising in the upper aerodigestive tract may metastasize to the lymph nodes of the neck. control of regional metastatic disease constitutes a significant part of the management of head and neck cancer. • Level I. Inflammatory (sarcoidosis). as well as pulmonary tuberculosis or mediastinal gland enlargement Anatomy The following definitions are recommended for the boundaries of cervical lymph node groups. p. The specific investigations will be dictated by the differential diagnosis. infectious mononucleosis. An ultra-sound scan (with USS guided FNA) or MRI scan may delineate impalpable nodes. but specific details are found elsewhere (see Benign neck lumps.CERVICAL LYMPHADENOPATHY Cervical lymphadenopathy implies disease involving the cervical lymph nodes. 3. Consists of the submental and submandibular lymph nodes within the triangle bounded by the anterior belly of the digastric. . A chest radiograph may show a primary carcinoma or evidence of secondary spread. so the information must always be used in conjunction with the clinical findings. The remainder of the chapter is confined to the problem of neck node metastases. radiology and laboratory tests.

which is based on data developed by the American Joint Committee (AJC) for Cancer Staging. 1. (a) Single ipsilateral node (3–6 cm in diameter). The performance of a neck dissection without palpable lymph nodes (prophylactic or elective neck dissection) is considered by some to be of doubtful value. Movable single homolateral node < 3 cm in diameter. Consists of lymph nodes around the middle third of the internal jugular vein extending from the carotid bifurcation superiorly to the cricothyroid notch inferiorly. Broadly speaking.CERVICAL LYMPHADENOPATHY 29 • Level II (upper deep cervical). Treatment The treatment of malignant neck nodes is by either some form of neck dissection or radiotherapy. Fifty per cent of nodes with a diameter greater than 3 cm exhibit this. The supraclavicular nodes are also included in this group. Consists of lymph nodes located around the lower third of the internal jugular vein extending from the cricothyroid notch to the clavicle inferiorly. NX N0 N1 N2 Regional lymph nodes cannot be assessed. the lymph node level and the presence of extra-capsular spread (ECS) are the most important prognostic parameters in metastatic disease of the neck. The argument supporting dissection is that some lymph nodes may be invaded by tumour (occult nodes) and still be impalpable. • Level IV (lower deep cervical). Nodes > 6 cm in diameter. The rupture of the lymph node capsule by tumour (ECS) is a bad prognostic sign. N3 Although this system is useful. • Level III (mid deep cervical). Risk factors for occult nodes . lymph nodes of less than 2 cm diameter can be treated by radical radiotherapy and those greater than this size will be treated by a neck dissection with or without postoperative radiotherapy. • Level V. it is generally acknowledged that the number of lymph nodes involved. This information is only available after pathological staging (pTNM). • Level VI. Regional lymph nodes not palpable. Consists of lymph nodes located around the upper third of the internal jugular vein and adjacent spinal accessory nerve extending from the level of the carotid bifurcation to the skull base. Postoperative irradiation to the neck following neck dissection is mandatory in the presence of ECS. it has several inherent problems: clinicians will fail to agree on the presence of a palpable lymph node in as many as 30% of cases. Movable homolateral or bilateral nodes. Staging The staging system in most common use in the UK is that proposed by the International Union against Cancer (UICC). In addition. (b) Multiple ipsilateral nodes (up to 6 cm). N0. (c) Bilateral or contralateral nodes (up to 6 cm). Consists of the posterior triangle nodes which are located between the posterior border of the sternomastoid muscle and the anterior border of trapezius. Anterior compartment.

a modified radical neck dissection on the least invaded side. There is support for elective treatment of the neck or at least the first echelon nodes in tumours of these primary sites. supraglottic larynx or oral cavity). The use of radiotherapy also means that valuable prognostic information (pTNM) is not made available. Patients with a supraglottic carcinoma and bilateral nodes do better than those with cancer of other primary sites at high risk of bilateral neck metastases (base of tongue and hypopharynx). N1. In approximately 3–11% of cases the primary tumour remains elusive and it is for these that the term ‘primary of unknown origin’ should be reserved. Postoperative radio-therapy is indicated if there is ECR or positive margins in the resection specimen. 4. radiotherapy has its own morbidity and can only be used once. However. For other sites it is argued that no survival benefit is conferred and the morbidity/mortality of the operation outweigh the potential benefit. The prognosis depends on N Stage and position of the node.g. It is generally accepted that lymph nodes of less than 2 cm diameter can be sterilized by radiotherapy. or the base of skull in the region of the mastoid process. Most surgeons advocate either staged bilateral radical neck dissection or. Therefore a modified radical neck dissection is preferred by some surgeons for these patients. but there is a high operative mortality. base of tongue and pyriform fossa). The treatment can be by selective neck dissection or by irradiation. such as the lungs.30 OTOLARYNGOLOGY are the site. Prophylactic neck dissection has a place in the patient who has a primary tumour with a high incidence of occult nodes (nasopharynx. tonsil. The decision to treat should be taken very carefully as there is a considerable morbidity from a bilateral neck dissection which can be a simultaneous or a staged procedure. It is important to search thoroughly for the primary tumour by all available diagnostic methods including history. Although recurrence after a course of radiotherapy can be treated by neck dissection. Supraclavicular nodes have the worse prognosis. These nodes used to be referred to as ‘fixed’. physical examination. N2. although overall survival is not affected. Invasion of the carotid artery can be treated with a bypass procedure performed with the resection. lung or stomach). If the tumour invades the internal jugular vein. ipsilateral tonsil excision. extranodal spread is uncommon. It must be confirmed that the node is metastatic as a high proportion of nodes in this category do not contain tumour and. This has the advantage of avoiding surgery and its morbidity. Patients who have neck dissection and radiation therapy to both sides of the neck and the mucosal surfaces have better neck and local control than . Many surgeons therefore adopt a wait and watch policy. 3. The prognosis varies from a 30–70% five year survival. Primary of unknown origin This term is applied to patients with a metastatic carcinoma in cervical lymph nodes with an ‘occult primary’. Larger nodes (N2a) and multiple ipsilateral nodes (N2b) are best treated by a modified or radical neck dissection because of the high incidence of ECR of the tumour and difficulty in sterilizing even small multiple nodes. even if they do. it is almost certainly incurable. A careful search will usually reveal the primary tumour in the skin or mucosal surfaces of the head and neck. The modality chosen is usually the same as that used for the primary tumour. N3. but size is now the criterion for staging. panendoscopy and selective biopsies from high risk sites (nasopharynx. the size and histological grade of the primary tumour. Fixation to the skin can be treated by resection of the tumour with involved skin which is replaced with the use of flaps such as a pectoralis major myocutaneous flap. The incidence of further neck recurrence is probably reduced by postoperative radiotherapy. or rarely. imaging. base of tongue. the survival after such salvage surgery is poor. or the brachial plexus. if possible. and little chance of cure. probably because many of these represent distant metastases from non-head and neck sites (e. in an area below the clavicles. pyriform fossa. 2.

Clinical Otolaryngology. Chemotherapy may have a place in improving this situation. Field JK. Death by carotid artery rupture will usually ensue. Prognostic factors of neck node metastasis. p. p.CERVICAL LYMPHADENOPATHY 31 those who do not have such extensive treatment. 1993. Clinical Otolaryngology. 72:1756–1761. this does not seem to translate into prolonged survival. Roland NJ. Palliative therapy Patients with inoperable neck nodes that have fungated through the skin can be treated with local dressings of kaltocarb and topical metronidazole. The level of cervical node metastases: their prognostic relevance and relationship with head and neck squamous carcinoma primary sites. However. 1982. 185. Neck dissection. Jones AS. Annyas AA. 19:63–69. Phillips D. 23. Squamous carcinoma presenting as an enlarged cervical lymph node. The patient should always be treated with appropriate doses of opiate analgesia and antiemetics. . 1994. Related topics of interest Benign neck lumps. Snow GB. It is imperative that there is adequate social support and that the patient’s family doctor is aware of the situation if the patient is to be cared for in the community. 7:185–192. Roland NJ. Van Slooten EA et al. Phillips DE. Further reading Jones AS. Cook JA. Cancer. These will help prevent colonization by anaerobes and alleviate the odour from tissue necrosis.

About half of infants with choanal atresia display other abnormalities. and there is a family tendency. R. which appear above the stomatodeum about the fourth week in utero. atresia choanae. Each nasal cavity is closed posteriorly by the thinned out posterior wall of the nasal sac. membrane. Clinical features A unilateral obstruction may be asymptomatic at birth but will later cause unilateral nasal discharge and obstruction. In addition. The nasal septum will then grow posteriorly to divide the two nasal cavities. The placodes deepen to form olfactory pits which lie between the medial and lateral nasal processes. and no airway can be demonstrated by holding a cold plated spatula below the nares—only the clear side steaming the surface (mirror test). The newborn is a near-obligate nasal breather and the nasal obstruction will therefore produce difficulty in breathing. Older children may allow posterior rhinoscopy to view the occlusion. or both. H. The medial processes fuse to form the frontonasal process. A. retarded growth and development. called the bucconasal membrane. colobama. . The alae nasi dilate and the accessory muscles of respiration are used to no avail. This results in the persistence of a bony plate (90%). This is compressed to form the nasal septum as the lateral nasal processes approach each other. The condition may be unilateral (most commonly) or bilateral. including the CHARGE association. Examination of the nose will show a thick gelatinous secretion on the affected side. palate. Bilateral choanal atresia presents as an emergency at birth. nose and paranasal sinuses all develop from the cranial portion of the primitive foregut. E. Its persistence is thought to be the cause of choanal atresia. obstructing the posterior nares. heart disease. ear abnormalities and deafness. G. There is pallor and cyanosis until the mouth is opened and after a few quick breaths are taken the infant cries. The diagnosis should be suspected immediately and an oral airway inserted to assist respiration. Embryology The mouth. This sequence of events continues. This usually breaks down around the sixth week in utero.CHOANAL ATRESIA Congenital choanal atresia is due to the embryological failure of the primitive bucconasal membrane to rupture before birth. genital anomalies. This refers to a problem of multiple congenital anomalies: C. half exhibit facial nerve palsies and one third of cases have laryngotracheal anomalies. It occurs in about 1 in 7000 births. The nose begins as two epithelial thickenings known as the nasal placodes.

Two approaches are in common use. and the occlusion removed together with part of the vomer and border of the hard palate. 232. Management Cases of unilateral atresia can initially be observed without treatment. Related topic of interest Paediatric airway problems. and to prevent granulation tissue formation and subsequent stenosis. p. The palate is incised just in front of the posterior edge of the hard palate. This is the usual approach in infants. This can also be accomplished with electrocautery or laser. but this period can be extended as the child grows. The treatment of choanal atresia is surgical. The soft palate is retracted. A membranous occlusion may require no more than perforation with a probe. The challenge is to provide a nasal airway which has an adequate mucosal lining. Fibreoptic endoscopy will confirm the diagnosis. This is preferred by some surgeons. A stent should be inserted and a series of dilations of the choana will then be required to maintain an adequate lumen. This will not be possible if there is an obstruction. A CT scan is the method of choice to delineate the nature and thickness of the obstruction. 2.CHOANAL ATRESIA 33 Investigations The diagnosis can be confirmed by the mirror test or by attempting to pass a catheter through the nose into the nasopharynx. In the more common bony occlusions it will be necessary to perform a trephine and remove the obstruction with a burr or potassium titanyl phosphate (KTP) laser using the operating microscope. Follow-up and aftercare Maintenance of the opening following corrective surgery with regular bouginage is now mostly preferred to the use of indwelling tubes. Dilation will probably be necessary every 2 months initially. particularly when the atresia is unilateral or if a previous transnasal opening has later closed. If there is still doubt the lesion can be demonstrated radiologically. 1. Transpalatal. Transnasal. In the case of the newborn with bilateral atresia the first priority is to insert and maintain an oral airway. .

Acquired cholesteatoma. carrying keratin and wax debris with it. (a) Primary acquired cholesteatoma associated with a defect in the pars flaccida. . replacing middle-ear mucosa. (b) Secondary acquired cholesteatoma associated with a defect in the pars tensa. The incidence is approximately 10 cases per 100 000 per annum. which in turn becomes infected and further expands under tension. 2. (c) Tertiary acquired cholesteatoma exists behind an apparently normal eardrum as a result of implantation or previous middle-ear infection. Congenital cholesteatoma has been shown by Michaels to be the result of the persistence of a small nidus of epidermoid ectoderm that occurs in the first trimester in the normal fetus and is normally resorbed.J. It may present later in childhood with extensive disease in an often cellular mastoid. theories regarding the aetiology of cholesteatoma. Put more simply. it is ‘bad skin in the middle-ear cleft’. Classification Cholesteatoma can be classified into congenital and acquired types. 1.CHOLESTEATOMA T. As it expands the isthmus tends to narrow. 1. the epithelium eventually loses its capacity to migrate out of the pocket and is trapped. There is no definitive classification of acquired cholesteatoma. Congenital cholesteatoma. Although initially self-cleaning. Aetiology There are a number of well-established. compounding the problem and continuing the cycle. The pocket fills with epithelial debris. but unproven. Therefore this skin is self-cleaning. Negative middle-ear pressure tends to pull the pars flaccida into the attic and may form a retraction pocket.H. This is the most common. (a) The single most important fact about the skin of the eardrum is that in health it migrates from the centre of the drum outwards along the external ear canal. It usually manifests itself as an anterior attic pearl behind an intact drum in the first year or so of life. resorbing underlying bone and tending to recur after removal. Primary acquired cholesteatoma. but it can be divided into three groups with reference to the tympanic membrane. These are distinct pathological entities.Lesser A cholesteatoma is a three-dimensional epidermal structure exhibiting independent growth.

respectively. with skin going in rather than continuing out along the ear canal. 2. The drum may heal or there may be a permanent defect. probably from toxins involved in chronic inflammation migrating through the round window. Electron microscopy shows normal epidermal cells plus Langerhan cells and Merkel cells. a marginal perforation or a pocket of invading keratin debris. lead to destruction of the bone locally. being naturally migratory. Pathology Macroscopically there is a rounded pearly white mass of variable size. A cholesteatoma invariably enlarges. but is often foul and creamy. Secondary and tertiary acquired cholesteatoma. Initially the cyst of skin grows into the area of least resistance. cholesteatoma is a benign keratinizing squamous cell cyst. (a) Epithelium could migrate around the rim of a pars tensa perforation to cause a cholesteatoma. often surrounded by friable granulations from infected bone or with polyp formation from infected mucosa. 134). Complications may occur in acute exacerbation of the disease and are either within the temporal bone or intracranial. In the centre are fully differentiated anucleate keratin squames. Behind these may lie a cholesteatoma so that micro-otoscopic removal of an attic crust or aural polypectomy may allow the diagnosis to be made. probably accounts for some of the growth. Clinical features Symptoms depend on the activity of the disease and arise either from the disease itself or from the complications. or sensory. Microscopically.CHOLESTEATOMA 35 (b) Direct invasion of migrating squamous epithelium through the pars flaccida may occur. . Infection with bacteria causes an increase in clinical progression. The epithelial matrix of acquired cholesteatoma has approximately 15 layers whereas that of congenital cholesteatoma has only about five layers. p. in turn surrounded by a matrix of inflamed subepithelial connective tissue. usually into the mastoid antrum and then into the air cells. Marginal granulations and polyps protruding from the middle-ear cleft indicate osteitis and mucosal hyperplasia. but other changes in the surrounding perimatrix. (d) Metaplasia of middle-ear mucosa may occur secondary to episodes of chronic or recurrent acute otitis media. but little is known as to how this growth is controlled. A positive fistula sign is said to indicate erosion into the labyrinth (see Labyrinthitis. The epithelium. waxy deposit. The principal signs are an attic crust. (b) Acute otitis media may damage the fibrous layers of the pars tensa and a piece of squamous epithelium may be implanted should the tympanic membrane rupture. The disease usually produces a discharge. which may be scanty or just a flaky. Deafness may occur—conductive secondary to ossicular erosion. either as papillae through a temporary defect or merely as a change in the direction of migration in the upper part of the tympanic membrane. These changes include the activation of osteoclasts and the production of lysozymes. surrounded by an epithelium several cell layers thick. probably brought on by infection. (c) Surgery involving trauma to the tympanic membrane (any middle-ear surgery or even grommet insertion) may occasionally allow squamous epithelium to be directly implanted. Dizziness may indicate a labyrinthine fistula. They are discussed under the topic complications of chronic suppurative otitis media (CSOM).

Related topics of interest Chronic suppurative otitis media—complications. Ludman and Wright (eds). Youngs R. . Further reading Ferlito A. p. it is often difficult on imaging to distinguish between cholesteatoma and pure mucosal disease. Cholesteatoma surgery today. Mastoidectomy. but the mainstay of treatment is surgical excision of the disease with reconstruction of the surgical defect and any conductive hearing loss. MRI likewise shows a mass with a low intensity T1 weighted signal and a high T2 signal. London. (b) Pure tone audiometry (with masking). Palva. p. Treatment Suction clearance may control early disease. 1998: 386–397. In practice. 107:483–488. 1993. 42. Journal of Laryngology and Otology. (c) Radiology. including the ossicles. p.341. Angled otoscopes permit examination of the facial recess and sinus tympani. 18:245–255. CT reveals a non-enhancing mass-eroding bone. CT and MRI can both demonstrate the disease and give some idea of its extent. Plain radiographs may indicate the height of the middle fossa dura and site of the sigmoid sinus but usually give little information on disease extent. 159. examination with a rigid lens otoscope and otophotography should be performed. A review of the definition. isodense with CSF.36 OTOLARYNGOLOGY Investigations (a) Micro-otoscopy (with the removal of attic crusts and polyps for reasons stated above).. In: Diseases of the Ear. Clinics in Otolaryngology. This usually takes the form of some type of mastoidectomy and tympanoplasty. If available. Arnold. T. Tympanoplasty. 1993. Chronic suppurative otitis media—cholesteatoma. with sharply defined smooth margins. terminology and pathology of aural cholesteatoma. 6th edn.

typically high pitched and vertigo. metaplasia of middle ear mucosa to respiratory type mucosa and poor mucociliary function. Disease is confined to the mucosa of the anteroinferior portion of the middle ear cleft. as is often quoted. perhaps because of an inadequate dose. there is slow resolution. length or inappropriate choice of antibiotic. Tubotympanic CSOM The essential features are a central tympanic membrane perforation and adequate atticoantral drainage. often triggered by an upper respiratory tract infection.CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM) This can be sub-classified into tubotympanic or safe. Pathogens gain entry to the middle ear either via the eustachian tube. CSOM without cholesteatoma is sometimes referred to as mucosal chronic otitis media and subdivided into active and inactive. Tinnitus. the risk of serious complications is minimal. Most perforations arise when an acute perforation occurs during an episode of ASOM and. On examination there is a wet or dry central tympanic membrane perforation. Chronic mucoid discharge is associated with goblet cell hyper-plasia. This allows sufficient time for squamous epithelium to migrate over the free edge of the tympanic layers to form a permanent perforation. The patient may notice the hearing improves when the ear discharges indicating there is an ossicular discontinuity which has been bridged by mucopus or a polyp. A classification gaining more prominence is chronic otitis media with or without cholesteatoma. Clinical features Deafness is proportional to the size of the perforation and not. The term ‘central’ implies there is a rim of tympanic membrane around the perforation and not that the perforation is centrally situated . This finding is also common with atticoantral disease. The disease is described as quiescent during the first few weeks of a dry ear and inactive when the ear is dry long-term and active when a mucoid or mucopurulent discharge within the middle ear is present. and tympanomastoid (atticoantral) or unsafe disease. or via the ear canal when contaminated bath. typically momentary and initiated by sudden head movement are usually associated with a high tone sensorineural hearing loss secondary to toxins reaching the perilymph through the oval or round window. swimming pool or sea water are the most common sources. the site. There is a 1–2% chance of developing a perforation when a ventilation tube is inserted and a 40% chance if a ventilation tube is in situ for more than 2 years. An air-bone gap of more than 30 dB is unusual and suggests an ossicular discontinuity.

the application of appropriate topical antibiotic ear drops. An infected polyp may protrude through the perforation and there may be signs of the complications of tubotympanic disease. Osteomyelitis of bone lining the polypoidal mucosa is the inevitable result. Episodes can also be secondary to acute labyrinthine failure which usually reverses spontaneously but if a permanent paresis occurs it may take several months before compensation is complete. lifestyle. • Tympanosclerosis. the frequency of recurrent infection. sometimes causing florid granulation tissue formation. Head and Neck Surgeons.38 OTOLARYNGOLOGY in the tympanic membrane. The current view of the British Association of Otolaryngologists. Intermittent benign paroxysmal positional vertigo has been described. Atticoantral CSOM Also called unsafe. in contrast to the British National Formulary entry and the Committee on Safety of Medicines. eradicating any source of intercurrent or chronic upper aerodigestive tract infection and to prevent water entering the external ear canal when swimming or bathing. It has been suggested that some subjects are predisposed to the latter because of a narrow epitympanic space and indeed it has been shown by high definition CT scanning of the petrous temporal bone that as a group these subjects have a gap between the scutum and medial middle ear wall that is significantly narrower than in a matched group without CSOM. High tone sensorineural hearing loss. Complications • • • • Otitis externa. age and general condition (see Tympanoplasty topic). until the ear is dry). the wish to swim and the patients occupation. prevent re-infection and to minimise the disability of any hearing loss. inadequate atticoantral drainage causes the mucosa to become chronically inflamed and polypoidal. the hearing in the contralateral ear. • Middle ear adhesions. The decision as to whether surgery in the form of a tympanoplasty or a hearing aid is more appropriate depends on the type and severity of the hearing loss. Intracranial and severe cochleovestibular symptoms are unusual as is a lower motor neurone facial palsy. is that the use of aminoglycoside antibiotics is reasonable in the presence of infection of the middle ear and a perforation (or grommet) for a limited period (i. especially the long process of the incus. Treatment The principles of treatment are to obtain a dry ear. Typically mild and transient.e. as the ear is at risk of serious complications. In the event of an episode of AOM. Ossicular erosion. Vertigo. . The incidence of intracranial complications in atticoantral CSOM is the same for ears with cholesteatoma or with pure mucosal disease. It is caused by either cholesteatoma or pure mucosal disease. The former is attained by frequent aural toilet. further compromising drainage.

Facial nerve paralysis secondary to chronic otitis media without cholesteatoma. 9:1. Journal of Hospital Infection. antibiotic ear-drops and systemic antibiotics. The former occurs when an ossicular discontinuity occurs from ossicular erosion by cholesteatoma or chronically inflamed mucosa. A marginal or attic perforation surrounded by granulation tissue or a polyp is more usual. 1999. Management of attic retraction pockets depends on their stage and in particular on whether they are self cleaning (see Cholesteatoma topic). in very elderly or those medically unfit. . the horizontal portion of the mastoid segment of the facial nerve was implicated as the site of involvement and the facial nerve palsy a neuropraxia which recovered with eradication of the cause. otalgia. A sanguinous discharge. Otoscopy may reveal no more than an attic crust which must be removed if cholesteatoma. The BAO-HNS Newsletter. attic granulations or a perforation are to be revealed. rarely responds rapidly to intravenous antibiotics because the mucosal changes or cholesteatoma are long-standing and surgical delay may compromise facial nerve recovery. Brook I. An unsafe ear without cholesteatoma which continues to discharge despite intensive medical management requires tympanomastoid surgery (see Mastoidectomy topic) as does the presence of cholesteatoma. a unilateral headache. As with ASOM. A high definition CT scan of the petrous temporal bone will show the extent but not the cause of soft tissue disease.CHRONIC SUPPURATIVE OTITIS 39 Clinical features Deafness may be a conductive. 1992. urgent surgery to irradicate all inflammatory disease is the priority. serous and chronic otitis media: the role of anaerobic bacteria. The latter should cover anaerobes because they have been found in over 50% of cultures in children with CSOM. If cholesteatoma is not seen on examining the ear. Complications • Extracranial. smelly aural discharge. Pure tone audiometry varies from normal air conduction if there is limited attic disease to a severe mixed type of hearing loss in extensive disease. signs of meningitis or of raised intracranial pressure suggest a serious complication. perhaps because of florid granulations. Toxin penetration through the round window may be the mechanism of sensorineural loss. lower motor neurone facial palsy. Pignatari SSN. Burke P. 13:372–374. polypoidal disease or granulation tissue. CSOM. • Intracranial. Scanty. mild transient vertigo and high pitched tinnitus are typical. sensorineural or mixed. an attempt must be made to dry the ear by means of regular aural toilet. Management The priority is to make the ear safe from intra cranial complications by eradicating disease. The management of acute. Facial nerve decompression is usually unnecessary. 1992. In cases of lower motor neurone facial paralysis associated with CSOM. Exceptions to this rule may arise when the ear is the better or only hearing ear. American Journal of Otolaryngology. 22 (suppl A): 75–87. in particular it does not distinguish between cholesteatoma. Further reading Harker LA. unlike ASOM.

Cholesteatoma. 5. 35. 159. p. . p.40 OTOLARYNGOLOGY Related topics of interest Acute suppurative otitis media. Mastoidectomy. p.

(b) By retrograde propagation of small foci of thrombophlebitis which may extend through the temporal bone and dura to the major venous sinuses to cause a lateral sinus thrombosis and by further extension a cerebellar or temporal lobe abscess. Classification 1. the sinus confluence. • • • • • • • • • Chronic otitis externa and meatal stenosis. (c) Along the periarteriolar spaces to cause a temporal or cerebellar lobe abscess. Intracranial. the superior sagittal sinus and the internal . Ossicular discontinuity from ossicular erosion. atticoantral mucosal disease and ASOM (see related topics) cause complications by spread of infection: (a) Directly via the oval or round window to reach the labyrinth. Serous or purulent labyrinthitis. Lower motor neurone facial nerve palsy. Extracranial. Middle ear adhesions. through osteomyelitic bone to reach the dura and lateral sinus or to affect a congenitally dehiscent facial nerve. Tympanosclerosis which may spread from the tympanic membrane over the ossicular chain causing ossicular chain fixation. Squamous cell carcinoma of the middle ear. • Lateral (transverse and sigmoid) sinus thrombosis. Petrositis and Gradenigo’s syndrome (signs of ASOM. Labyrinthine fistula. an ipsilateral abducent nerve palsy and pain in the distribution of the ipsilateral trigeminal nerve). Cholesteatoma. This may extend to involve the superior and inferior petrosal sinus. the cavernous sinus. Browning in a retrospective study has calculated that the risk of a patient with CSOM developing an intracerebral abscess is 1 in 3500. 2.CHRONIC SUPPURATIVE OTITIS MEDIA— COMPLICATIONS Complications of CSOM are associated with a high morbidity and may be life threatening.

The diagnosis should be confirmed by needling the sinus. found in 6% of ears. vascularized thrombus. A gadolinium enhanced magnetic resonance scan is now the investigation of choice for the diagnosis of an intracranial venous thrombosis (simple thrombus shows an intermediate signal. clumsiness. granulation tissue and slow flowing blood a high signal. forgetfulness or drowsiness should have a full neurological examination looking in particular for signs of raised intracranial pressure. • Otitic hydrocephalus. In this instance the palsy may be a neuropraxia of a dehiscent horizontal segment of the nerve. vomiting. visual disturbance. • Neurosurgeons to manage intracerebral abscess. 1. • Meningitis. There is often a concomitant extradural or subdural abscess which may have precipitated the formation of the thrombus. The lateral sinus is opened. . 2. Treatment • High dose intravenous antibiotics to commence after taking a culture swab of the aural discharge.42 OTOLARYNGOLOGY jugular vein. intracerebral (cerebellar and temporal lobe) abscess. • Treatment of initiating otological disorder. Subdural and extradural abscesses require a cortical mastoidectomy to provide adequate exposure before drainage. After confirmation some practitioners propose tying the internal jugular vein high up in the neck to prevent infective embolization during evacuation of infected clot. meningitis and localizing cerebellar and temporo-parietal lobe signs. Patients with CSOM who present with unilateral or occipital headaches. subdural. A facial palsy secondary to ASOM is invariably a neuropraxia. Most otologists advocate an urgent mastoidectomy and decompression of the vertical segment of the facial nerve though this has recently been challenged. If there is an actively discharging ear others would observe for at least 48 hours with the patient on intravenous antibiotics. and fast flowing blood no signal) and intracranial abscess (shows a centre of low attenuation with an outer rim of high signal). A lateral sinus thrombosis if not responding to high dose intravenous antibiotics should have a cortical mastoidectomy and the lateral sinus exposed. The nerve does not require decompressing and should recover rapidly with aggressive treatment of the infection. Clinical features Patients with acute intracranial complications usually present to the neurosurgeons and are most likely to be seen by an ENT surgeon after recovery from the acute episode. the clot evacuated and the sinus obliterated with a temporalis muscle flap reinforced by a bismuth iodoform paraffin paste (BIPP) mastoid pack. Investigations A high definition CT scan of the petrous temporal bone will show the extent of mastoid disease although it may not distinguish cholesteatoma from mucosal disease. The facial palsy in CSOM is usually secondary to compression from cholesteatoma or granulation tissue. • Extradural. A deep throbbing otalgia and serosanguinous discharge may herald malignant change.

Herzog JA. Cholesteatoma. 1992. 35.CHRONIC SUPPURATIVE OTITIS MEDIA—COMPLICATIONS 43 3. Labyrithine fistulae may be caused by erosion of bone by cholesteatoma and by osteitis with the formation of granulation tissue. Smith PG. Further reading Munz M. Management of labyrinthine fistulae secondary to cholesteatoma. Journal of Otolaryngology. Maxwell KS. 1997. 21: 224–226. p. or alternatively. p. 2) the matrix can be peeled off under constant irrigation and the fistula immediately sealed with fascia or muscle as the final manouvre in surgery. et al Otitis media and CNS complications. . Acute suppurative otitis media. Farmer JP. In cholesteatoma the matrix usually becomes apposed to the endosteum within the fistula and a protective walling off does not arise. Related topics of interest Chronic suppurative otitis media. 17:410–415. Auger L. 38. American Journal of Otolaryngology. p.5. If a fistula is suspected from clinical signs and operative findings then either: 1) the matrix can be left over the affected portion of the labyrinth and a canal wall down procedure performed leaving an open cavity. Klester GR.

. 1. audiometry on occasions may be inaccurate or unavailable. There is a risk of under-masking if the sound level of speech arriving at the test ear is greater than 70 dB(A) so a Bárány noise box should be used when testing an ear with a severe or profound impairment or when testing bone conduction with tuning forks. The tragal rub. The maximum sound output varies from approximately 90 dB(A) when a box is held at right angles to the ear and 100 dB(A) when held over the ear.CLINICAL ASSESSMENT OF HEARING Use of clinical tests It is surprising how often a clinical assessment of hearing is omitted from the routine examination of the otology patient. Voice tests and tuning fork tests are the two main methods. It should be used when a tragal rub does not provide adequate masking. However. There are two techniques in common use. Determine the nature of a hearing loss (conductive or sensorineural). but the main problem is cross-masking of the test ear. Using this technique speech will be attenuated by approximately 50 dB. Masking Masking is as important in clinical testing as it is in audiometric testing. These levels are sufficient to mask the non-test ear in all practical circumstances. exaggerated thresholds may be missed if suspicion is not aroused by clinical testing. This box produces a broad-band noise from a clockwork-driven source. Occlusion of the auditory canal by putting finger pressure on the tragus with a rubbing motion is the easiest method. 2. The main reason that clinical tests of auditory function are overlooked is that they have largely been superseded by more sensitive and reliable audiometric tests. but often only the Weber and Rinne tuning fork tests are performed. Detect feigning or a non-organic hearing loss. Bárány noise box. The non-test ear should always be masked when clinically testing by air conduction. and in theory always when performing tuning fork tests. Furthermore. though this is not always practicable. Grade the severity. Proponents of clinical testing suggest that audiometry may be unnecessary if the hearing is normal or the results would not influence the management. Clinical tests can be used to: • • • • Identify a hearing impairment.

For bone conduction the base plate should be placed firmly on the skull. and finally to a loud voice at 15 cm. . It is usual to start by testing the better hearing ear when there is one. The inner ear is normally twice as sensitive to sound conducted by air as to that conducted by bone. cowboy). A tuning fork should be set in vibration by a firm strike one-third of the way from the free end of the prong against a firm but elastic object (e. The duration of the stimulus decreases with increasing frequency. The examiner starts using a whispered voice 60 cm away from the patient. to a conversational voice at 60 cm.g. Forks with a frequency lower than 256 Hz can make it difficult for the patient to distinguish between hearing the sound and feeling it by vibration. some points may give less reliable results. bluebell. conductive from sensorineural.63) or combinations of numbers and letters (e. Ideally a 512. a number of tests have stood the test of time and continue in current clinical practice. The non-test ear is masked by a tragal rub unless a loud voice is required (use the Bárány noise box).g. to a conversational voice at 15 cm. However. If a patient can hear a whispered voice 60 cm away from the ear. 4 B 7) can be used depending on the patient’s age and understanding. Patients who can hear a whisper at 15 cm or a conversational voice at 60 or 15 cm are likely to have thresholds in the range of 30–70 dB hearing level (HL) (mild/moderate impairment). the pure tone thresholds are likely to be less than 30 dB (normal hearing). This should produce a relatively pure tone with minimal overtones. Tuning forks Tuning forks for audiological use are modified to include a finger grip on the stem and an expansion on the base of the stem to allow application to the skull. many of these tests are no longer in everyday use. the affected ear is subject to less environmental noise. conversational voice and then loud voice at 60 cm and then 15 cm. Bisyllable words (e.g. 2. It can then be presented by either air or bone conduction. elbow or patella). With the advent of newer and more sensitive forms of investigation. The easiest and best method of performing monaural free-field voice testing is by using a whispered voice.37. For air conduction it should be held with its acoustic axis (a line joining two points near the tips of the two prongs) in line with and 2–3 cm from the external meatus. to a whispered voice at 15 cm. The tests are based on two main principles: 1. which is the furthest away that is possible when masking the non-test ear. and it is difficult to activate forks with a frequency higher than 512 Hz sufficiently for them to be heard by those with a moderate or severe impairment. to a loud voice at 60 cm. making it more sensitive to bone-conducted sound. In the presence of a purely conductive hearing loss. The test finishes as soon as the patient repeats 50% of the words correctly at any one voice and distance level. to differentiate real from feigned hearing loss. and cochlear from retrocochlear hearing loss.CLINICAL ASSESSMENT OF HEARING 45 Voice tests Difficulties in standardizing the technique and variability of the stimulus provided by the examiner have led to criticisms of this test. Those patients who can only hear a loud voice are likely to have thresholds greater than 70 dB HL (severe/profound impairment).g. The patient is asked to repeat as accurately as possible what the examiner says. The sound level is increased in steps from a whispered voice at 60 cm.or 256-Hz tuning fork should be used. 54. Although the tuning fork can theoretically be placed at any point on the skull for bone conduction. either mastoid process or vertex depending on the test. A variety of tuning fork tests were developed to test absolute hearing thresholds (compared with the examiner). numbers (e.

Rinne test This test examines each ear individually and is again based on the principle of improved bone conduction perception with a conductive loss. the sound will appear to originate from that side alone. minimally attenuated. If the intensity of one side is increased. Weber test This test is based on the principle that a conductive loss causes a relative improvement in the ability to hear a bone-conducted sound and the test is of most value in a unilateral hearing loss. the sound will be heard in the midline. tuning fork tests are unreliable in children. the sound will appear to originate in the midline. The former is referred to as a true-negative Rinne and the latter as a false negative. The tuning fork is struck and placed on the subject’s mastoid process. the test is commenced by asking the subject to close his or her eyes to help concentrate on the sound. if two pure tones of equal intensity are presented to both ears at once. The tester works behind the subject. After the subject acknowledges hearing the sound. If the sound does not change or becomes quieter. Occluding the external auditory canal will block out ambient noise. the response is positive (and normal). A negative response (Rinne negative) will occur if there is a conductive loss of greater than 20 dB or if there is a severe sensorineural hearing loss. (Further improvements can be achieved by using the upper incisors but these are not always available!) If a conductive loss of 10 dB or more exists. If the sound becomes louder. the response is negative. The normal response is to hear the sound as louder and longer with air conduction and is referred to as a Rinne positive. A positive response will also occur with a sensorineural hearing loss. bone conduction is masked. from escaping. First a tuning fork is placed 15 cm from the good ear. The subject can be asked to compare either the loudness of the tuning fork when presented by air conduction and bone conduction (placed on the ipsilateral mastoid process) or the duration of the sound when presented by both air and bone conduction. in which case the false negative will become positive as the contralateral. and usually indicates a conductive loss of 10 dB or more. If a sensorineural hearing loss is present the sound will generally be heard in the normal ear. The two can be distinguished by using a Bárány sound box. The vertex is used as opposed to the forehead as the reliability of the test is thus improved from 72% to 86%. In practice. Bing test This test is similar to the Rinne and is based on the improvement in bone conduction perception in the normal subject when the external auditory meatus is occluded. Unfortunately. It can be performed in one of two ways. In the normal subject or some subjects with a long-standing sensorineural hearing loss. the ipsilateral meatus is occluded by the examiner’s finger and the subject is asked if this makes the sound louder or quieter. the subject . the sound should be heard in the affected ear.46 OTOLARYNGOLOGY No single test is diagnostic but all can provide useful information when taken in context. The tuning fork is struck and placed on the vertex. which has emanated into the external auditory canal. Stenger test This test is used to differentiate a real from a feigned hearing loss and is based on the principle that. and prevent some of the bone conduction sound.

Stephens SDG. Journal of Laryngology and Otology. A tuning fork is then positioned 5 cm from the bad ear. Finally. Further reading Browning GG. Some tuning fork tests revisited. If the hearing loss is feigned. Impedance audiometry p. two tuning forks are used simultaneously: one 5 cm from the bad ear and one 15 cm from the good ear. p. Clinical Otolaryngology. 1933. the subject will deny hearing anything and this suggests the diagnosis. 1979. the subject will hear the sound loudest in the bad ear. 1986. Speech audiometry. 128. 23–37. . p. Pure tone audiometry. p. the subject will deny hearing it. unknown to the subject. Report of the committee for the consideration of hearing tests. Clinical Otology and Audiology. 301. If the hearing loss is real the subject will hear the sound in the good ear and report this. 4:421–430. 254. 82. 48:22–48. Committee for the consideration of hearing tests. 194. London: Butterworths. Non-organic hearing. loss p. Golabek W. Related topics of interest Examination of the ear.CLINICAL ASSESSMENT OF HEARING 47 confirms hearing the sound. Unaware that there is a previously audible sound present at the good ear.

to draw up and agree a development plan and clarify reporting arrangements. Continuing professional development for all staff. research. A mechanism to ensure all systems are in place and functioning effectively. to carry out a baseline assessment of capability and capacity. Continuing education for all clinical staff. Evidence-based clinical practice. The systems embraced by clinical governance include: • • • • • • • • • • • • • Clinical audit. Systems to ensure lessons learnt are implemented.CLINICAL GOVERNANCE AND AUDIT Clinical governance In 1997 the government published the first of its white papers on quality within the NHS and introduced the term clinical governance. NHS organizations are presently NHS Trust Boards and the chief executive is ultimately accountable for assuring the quality of services provided by the Trust. Development of clinical leadership skills. Developing guidelines and protocols. Managing the clinical performance of colleagues. sharing of good practice and multidisciplinary team-work thrives. The third white paper—‘Clinical governance: Quality in the new NHS'—emphasizes the need for a move to a culture of learning in which education. developing guidelines and protocols. community providers and primary care practices. Health-needs assessment. Clinical governance is defined as ‘A framework through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’. Risk management. Audit of consumer feedback. Each health organization will be required to set up leadership and accountability arrangements. . Accreditation of hospitals.

Determining methodology. evaluate. Developing ways of involving users and carers in the planning of service improvements. A working group of the World Health Organization defined audit as a 7-stage procedure. The guidelines are: • • • • • • • Problem identification. • It is educational and raises the overall quality of care. Comparing performance with standards. Setting criteria and standards. The reasons for performing audit are: • To encourage modification and improvement in clinical practice. Being aware of best practice guidelines from NICE and adopting them as part of clinical audit or individual practice development. 6. 3. Working within the team to look at the strengths and weaknesses of the services they deliver and propose ways for improvement. This should include the assessment of patients access to care. Audit Audit is defined as the systematic appraisal of the implementation and outcome of any process in the context of prescribed targets and standards. 4.CLINICAL GOVERNANCE AND AUDIT 49 New national bodies 1. National Institute for Clinical Excellence (NICE) will set national standards and best practice guidelines. In the clinical setting the problem with this definition is what to define. and improve their practice. as reasonable targets and standards and this requires research. Re-evaluating the quality of care. 5. Clinical audit is the process by which medical staff collectively review. the most vital element being to ensure an improvement (indicating change) in care by reassessing results after the setting of criteria and standards. Leading and participating in quality improvement activities in service delivery. the process and outcome of care and financial and administrative efficiency. Setting priorities. Designing and implementing remedial action. 2. Commission for Health Improvement (CHI) will inspect NHS organizations locally to ensure that clinical governance and the standards set by NICE are being implemented. • To allow peer review and support for clinicians. For individual practitioners these changes will mean: 1. . Taking a full part in continuing professional development programmes. for each aspect of medicine. Playing a part in the organization’s assessment of its present capacity for quality improvement. 2.

for example beds. relatives and their legal representative are allowed access to medical but not audit records. admission and outpatient waiting times. Type II errors in assessing clinical outcome might be averted. The National Confidential Enquiry into Perioperative Deaths (NCEPOD) Perioperative deaths are those which occur within thirty days of a surgical procedure. National Audit This is necessary because each hospital. A sample of the reported deaths are reviewed in greater detail by the steering group by sending questionnaires regarding all aspects of the patient’s care in the perioperative period to the consultant surgeon and anaesthetist in charge of the patient’s care. drugs. In other words audit tests either process or outcome after research has established that there is a link between them. The guidelines are issued from information provided mainly by pathologists who supply data regarding perioperative deaths in their hospital. NCEPOD provides guidelines annually for specific clinical situations with the aim of improving surgical practice. The recommendations come from an independent body with representatives across the surgical speciality fields (the steering group) nominated by an elected body in that speciality (in Otolaryngology it is a British Association of Otolaryngologists and Head and Neck Surgeons [BAO-HNS] proposed representative). district and even region has a relatively small number of clinicians performing a proportionately small number of procedures compared to the national total. investigations and duty theatres should be determined and if appropriate. investigations. • Each meeting should attempt to provide a specific recommendation which when implemented improves clinical practice. proposals made with the purpose of making them more efficient. Hospital managers are allowed access only to the conclusions of any meeting. It allows prescribed targets and standards to be defined and may allow a management policy for a specific condition to be drafted.50 OTOLARYNGOLOGY Research and audit Research and audit are often confused and it is important to clarify the difference. that is any procedure carried out by a surgeon or gynaecologist. with or without an anaesthetist. • Treatment policies should be reviewed to minimize morbidity and mortality and maximize quality of life. Anonymity of sensitive data must be secured. • Departments should set targets regarding appointments. Clinical research tests hypotheses so that they may be accepted as scientific fact or refuted in order to establish what is the best clinical practice. In this context it should be remembered that patients. involving local. • Clinical audit regularly undertaken may provide a basis for a successful medico-legal defence because it can be shown that treatment has been researched and reviewed. . • The use of resources. regional or general anaesthesia or sedation. Important aspects of clinical audit are: • Clinical audit meetings should be confidential and involve only clinicians specifically involved in patient care. Audit on the other hand seeks to determine whether good practice (the process) has been adopted or whether the prescribed targets and standards gained through research are being met (the outcome).

The new NHS: modern and dependable. Guidelines to Clinical Audit in Surgical Practice. The organization of quality assurance. 1997 (Cm. Department of Health. London: Department of Health. London: The Royal College of Surgeons of England. Clinical governance: Quality in the new NHS. 1: 111–123. Bull AR. London: Department of Health. A First Class Service: Quality in the new NHS. Audit and research: complimentary but distinct. March 1989. 1989. 1999 (Health Service Circular: HSC (99) 065). Department of Health.3807). Annals of the Royal College of Surgeons of England. Quality assurance in health care. . 75:308–311. London: The Stationary Office. 1993. 1998 (Health Service Circular: HSC (98) 113). Department of Health.CLINICAL GOVERNANCE AND AUDIT 51 Further reading WHO Working Group.

Sound received by the microphone is converted into electrical energy. implant programmes in the UK were funded through research and charitable sources. History The first report of cochlear implantation was from Djourno and colleagues in 1957 who described the insertion of a device into two totally deaf individuals. thereby stimulating residual auditory neural tissue. USA. but the MRC report by Summerfield and Marshall (1995) based on a multicentre pilot study. the original premise that cochlear implantation would allow recognition of environmental sound and serve as an adjunct to lipreading has been realized. which is conveyed to the speech processor. this stimulated considerable interest in the 1960s and 1970s among several investigators: the House group in Los Angeles. The success of these early implant programmes generated considerable interest in the UK: the first single channel device was implanted in London by Fraser in 1984 with the first multichannel device being inserted by Ramsden in Manchester in 1988. many of the original and current commercially available devices bear their origins in these pioneering research programmes (3M and Clarion devices from California. The device aims to provide perception of sound by attempting to emulate the transducer function of the cochlea. Paralleled by developments in pacemaker technology. in effect procured central funding for cochlear implantation. Initially. Not surprisingly.COCHLEAR IMPLANTS S.Saeed Over the last decade cochlear implantation has evolved to become an established means of auditory rehabilitation in selected adults and children with severe or profound hearing loss. In reality. The external part comprises a microphone. This body worn component utilizes various speech strategies (see below) and sends the processed signal to the transmitting coil which is held on the scalp behind the ear by a magnet in the coil and the implanted part of the device. USA. From the receiver-stimulator package. Nucleus devices from Australia and Med-El devices from Austria). USA.R. many individuals have derived greater benefit including the ability to understand speech with little or no lip-reading. Implant design Current cochlear implants consist of two parts: an external component and a surgically implanted internal component. Michelson and colleagues in San Francisco. Australia. Clark and colleagues in Melbourne. In appropriately selected individuals. Hochmair-Desoyer’s team in Austria and Chouard and colleagues in France. speech processor and transmitter coil. The transmitter coil transfers the processed information to the internal implanted receiver-stimulator package by transcutaneous induction. The microphone unit is hooked behind the ear in a manner not dissimilar to a conventional behind-the-ear hearing aid. information is conveyed to the electrode array which is implanted within the cochlea: the current hypothesis .

a third group are those children that lose their hearing around the time of speech development (perilingual). In terms of outcomes. By stimulating a smaller number of the available electrodes with the signal components that have the highest amplitude the overall rate of stimulation increases. The implementation of the principles of the speech strategies differs between manufacturers and continues to evolve.and perilingual children the timing of cochlear implantation is critical taking into account the issues of neural plasticity. Various speech coding strategies have evolved over the last 20 years in an attempt to emulate and present this information to the auditory nerve. the current strategies for multichannel implantation from the different manufacturers are all capable of providing comparable results. The implanted component of the device needs to be constructed from biocompatible materials with high tensile strength and resistance to corrosion. Modified electrode arrays are available for use in the partially ossified cochlea: compressed arrays carrying a smaller number of electrodes or double electrode arrays for insertion into the basal and middle cochlear turns independently. is lost by the age of 8 years whilst the ability to develop good speech articulation only occurs if speech sounds are heard by the age of 3 years. At the time of writing. Auditory plasticity. hearing impaired individuals are classified as postlingual (speech acquired before becoming deaf) or prelingual (become deaf before acquiring speech). A family history of longevity may also be taken into consideration. enhancing temporal information. Speech coding strategies A speech signal has two main components: spectral (pitch) information and temporal (loudness and change in loudness) information. Candidacy The process of selecting appropriate individuals for implantation is of critical importance for a successful outcome and is task that involves all the members of the implant team. This reduces cross-interaction between channels thereby enhancing spectral information. On this basis. however. The electrodes themselves are made of a platinum-iridium alloy housed in silicone with either a ceramic or silicone casing for the receiver package. The selection criteria continue to evolve and may be considered under the following headings: 1. There is no upper age limit as long as the potential recipient is in good health. Current devices digitize the input and utilize band pass filters to divide the signal into frequency specific components. the number of active electrodes varies from 12 to 24 (multichannel devices). Age. In addition. the cost of the implant hardware in the UK is around £ 15 000. and with it the ability to listen. In pre. In cochlear implantation two components are of paramount importance: changes in the brainstem auditory nuclei and the auditory cortex in response to sound and also the neural plasticity of speech articulation. This information is presented in a pulsatile waveform to the individual channels of the electrode array. Profoundly deaf prelingual adolescents and adults. Postlingual adults and children may be considered for implantation. The original strategies based on extracting vowel and fundamental formant information are now obsolete.COCHLEAR IMPLANTS 53 is that the implanted electrodes stimulate the spiral ganglion cells of the auditory nerve directly. Neural plasticity This is the ability of the central nervous system to be programmed to learn a task. The initial controversy surrounding implantation in children . Depending on the manufacturer. are unlikely to derive benefit from cochlear implantation as the neural plasticity required to make sense of the auditory stimulation from an implant has already been lost.

Audiometric and vestibular assessment Selected individuals that derive little or no benefit from a trial of conventional hearing aids may be considered for cochlear implantation. Active chronic suppurative otitis media remains a contraindication to implantation. 4. the tympanomastoid cleft can be evaluated for the presence of any infection or cholesteatoma and surgery can proceed if the ear is disease free. electrical response audiometry is utilized to confirm the presence of a profound hearing loss and to act as guide as to which ear to implant. Two imaging modalities are utilized. Otological examination. In addition. In the presence of cardiovascular or respiratory disease. the relationship between the onset of deafness and speech development is of critical importance. secondary changes in the cochlea such as fibrosis and ossification (such as after meningitis) need to be recognized as surgery may require a cochlear drill-out or use of a modified electrode array as described above. Radiology may also demonstrate the aetiology in ‘idiopathic cases’ such as the large vestibular aqueduct syndrome or previously undiagnosed cochlear otosclerosis. autoimmune hearing loss and labyrinthitis due to causes other than meningitis. Duration of severe or profound deafness. The principle of assessment of the patient’s general health prior to elective surgery under general anaesthesia applies as for any other planned otological surgery. soft tissue opacification of the tympanomastoid cleft and the anatomy of the jugular bulb. Within the cochlea. 3. However. 6. In addition. CT scanning may fail to demonstrate cochlear fibrosis and therefore in post-meningitic deafness T2 weighted MR imaging is the investigation of choice. Cause of the deafness. In . Imaging aims to firstly establish the presence of a normal cochlea (not always the case in congenital deafness) and to establish cochlear patency. If implantation is to be undertaken in the ear with better or only vestibular function then appropriate preoperative counselling needs to be discussed with the patient.54 OTOLARYNGOLOGY has abated and successful implantation has been undertaken in selected children below the age of I8 months. Radiological assessment. the duration of severe or profound deafness is recognized as a prognostic indicator with respect to outcome. Implantation is indicated in deafness due to cochlear pathology: central and auditory nerve causes are a contraindication. In postlingually deafened adults. At the time of implantation. The standard examination is a high resolution CT scan. This is a mandatory part of the evaluation process. particularly after meningitis. with those individuals deafened for more than 20 years tending to fare less well. 5. In children. a decision has to be reached in terms of the risks of surgery against the benefits of implantation. The audiological evaluation includes aided and unaided pure tone audiometry and speech audiometry. In addition. Surgery to render the ear disease free must be undertaken as a prelude to insertion of the device. More recently. the severity of other disabilities such as blindness and locomotor dysfunction also require careful consideration. General medical history. This may also be considered the case in deafness due to otosclerosis. appropriate radiology gives information about the internal auditory meatus (the narrow meatus with normal facial function may only contain a facial nerve) and provides general information about the temporal bone anatomy such as pneumatization. Central compensation occurs more readily in children than adults and the latter will require a caloric test to establish the presence or absence of labyrinthine function. Loss of vestibular function may accompany the hearing loss. different aetiologies have a greater or lesser effect on the spiral ganglion cell population. 7. with the observation that many implanted individuals seem to fare better than marginal hearing aid users several centres now use a 30% speech score as the ceiling for consideration for implantation. particularly those with congenital deafness. This is usually staged with obliteration and blind-sac closure of an open mastoid cavity if present. The original criteria for implantation were pure tone thresholds greater than 100 dBHL at 2 kHz and above with speech discrimination scores less than 10%. 2. With regards to children and adolescents.

In children the expectations and motivation of the immediate family are also of critical importance. Some surgeons prefer to enter the basal turn via the round window itself. A cortical mastoidectomy with undermined margins is undertaken and a bed drilled in the skull for the receiver-stimulator package. The electrode array is guided into the cochlea and advanced using a claw designed for this purpose. The receiver package is then secured in its bed either with ties or bone cement.COCHLEAR IMPLANTS 55 selected cases both types of imaging will be required in order to fully assess the feasibility of inserting the electrode array. In children considerable support from their teachers is required with close co-operation between the implant team and the educationalists. . The opening into the scala tympani is made just in front of and above the round window niche. The expectations of the potential adult recipient need to be realistic: the implant does not restore hearing in the natural sense and the patient needs to understand this. In addition the individual needs to be motivated for the intensive rehabilitation that will be required to maximize the potential from the device. Surgery Surgery is usually undertaken under general anaesthesia after informed consent with particular reference to the facial nerve and chorda tympani. an intensive programme of auditory and speech training takes place with fine tuning of the speech processing map for the particular individual. Psychological profile and expectations. The author routinely uses a facial nerve monitor and parenteral antibiotics are given at the start of surgery with two further doses postoperatively. The patient is usually fit for discharge on the third day post operation and the sutures removed at 1 week. An attempt is made to initially preserve the endosteum of the scala tympani and to open into the basal turn with a needle rather than the drill. The full benefit of the implant is not usually realised for at least 6 months and may take 12–18 months when the learning curve flattens and the recipient adjust to the new auditory stimulus. The proximal electrode array lies under the undermined margins and may also be secured with ties. The rehabilitation process continues for several months for adults and years for children. Rehabilitation The initial ‘switch on’ of the device usually occurs after about 4 weeks when all the postoperative scalp swelling has settled and the wound is fully healed. The facial recess is approached via a posterior tympanotomy preserving a bridge of bone between the tympanotomy and the fossa incudis. thereby reducing the risk of trauma to the spiral lamina and remaining neural elements. rehabilitation requires numerous visits to the implant centre possibly over several years and the family need to commit themselves and the child to this process. For several weeks after this. Two types of skin incision are commonly used: the extended endaural and modified post aural. A muscle plug is used to seal the cochleotomy and the posterior tympanotomy conferring further stability. The tympanotomy should allow visualization of the incudostapedial joint and the round window niche to allow correct placement of the cochleotomy. The musculoperiosteal flap is usually raised separately. 8. clips or bone cement. In particular. An attempt is made to insert the array as far into the cochlear duct without damaging the array. A plain transorbital X-ray is undertaken the day after surgery to confirm the position of the electrode array in the cochlea. The wound is closed in the conventional manner and a mastoid dressing and pressure bandage applied for 48 h.

open set tests are commonly used. Injury to the facial nerve is rare whilst chorda tympani trauma is probably under-reported. All are uncommon and the offending electrode or electrodes can usually be programmed out. With experience and meticulous attention to incision placement and soft tissue handling major scalp complications can be avoided. The majority of adults report identification of environmental sound and a marked improvement in their lip reading skills. Of the prelingually deafened children around one half developed open set listening with good or average speech intelligibility. Future developments Cochlear implantation is a fertile area for research and development both by implant teams and the manufacturers. necessitating re-implantation. magnetless coupling mechanisms and refinements in speech processing strategies. In one series almost all the postlingually deafened children developed open set listening with good speech intelligibility. Such events have been reported by all the implant manufacturers and tend to occur early in the life of the device. Current clinic studies include bilateral implantation. Non-auditory stimulation. Surgical complications. Complications 1. 3. This is probably because surgeons undertaking this type of work already have a considerable otological experience and international implant workshops are readily available for those embarking on this type of surgery. Damage to the electrode array and electrode misplacement have been reported in most large series. Device malfunction is categorized as a soft failure if there is deviation from the specification without total loss of function (such as an electrode fault that can be programmed out) or as a hard failure if the implant ceases to function. therefore. scalp or throat. implantation in marginal hearing aid users. cochlear implantation in patients with bilateral vestibular schwannomas and evaluation of music perception. 2. Undesirable effects of electrical stimulation of the inner ear include pain in the ear. A sizeable proportion are able to track speech without lipreading and a smaller number can. With continuing research and development device failure has become less common and by way of example.56 OTOLARYNGOLOGY Outcomes Numerous tests have been developed to evaluate the outcome of implantation in a given individual. particularly when listening to familiar voices. intrusive tinnitus and facial nerve stimulation. Hardware developments include modiolus hugging electrode arrays. . In adults. the cumulative survival for devices from one of the manufacturers is greater than 98% after 5 years. Surgical complications in cochlear implantation are in fact relatively uncommon. The outcomes in children are dependant on their language status at the time that the hearing was lost and to a degree on the age at implantation. to see children implanted at the age of 2 or 3 years entering mainstream education at the age of 5 or 6 years. Such tests assess the ability to distinguish speech without any contextual clues or lip reading. It is not surprising. Facial nerve stimulation is a particular feature in those individuals deafened by otosclerosis or temporal bone fractures and it is postulated that the fracture line or otospongiotic focus allows current escape and stimulation of the intralabyrinthine segment of the facial nerve. The ultimate goal is the totally implantable device which is probably only a few years away. Device complications. One of the most serious complications is ischaemia or sepsis in the scalp flap with loss of flap viability around the receiver package. in ideal conditions converse almost normally or use the telephone. This situation is difficult to salvage and may result in device extrusion and subsequent need to remove the device.

1997. pp. Scott-Brown’s Otolaryngology. 18 (Suppl6): 1–170. Oxford: ButterworthHeinemann. 1–25. . In: Booth JB (Ed). The American Journal of Otology. Cochlear implants. Gibson WPR.COCHLEAR IMPLANTS 57 Further reading Various authors. 1997.

Branchial arch anomalies. Recessive genes account for 80% of hereditary deafness. 2. Pendred’s syndrome. 3. saddle nose. Hypoplastic mandible. There are a multitude of syndromes associated with congenital deafness. cleft palate.CONGENITAL HEARING DISORDERS We define the term congenital as existing at birth. 2. external and inner ear abnormalities. acrocephaly. Branchio-oto-renal syndrome. glossoptosis. peripheral neuropathy and SNHL. Telecanthus. cerebellar ataxia. Treacher-Collins syndrome. renal dysplasia and a mixed type of hearing loss. parrot beak nose. Pierre-Robin syndrome. cleft palate. 5. Waardenburg’s syndrome. Congenital deafness may be sensorineural. Sensorineural hearing loss (SNHL) and a thyroid goitre. There may be microtia or multiple. 4. 4. syndactyly. pigment disorder (20% have a white forelock and 45% heterochromia iridis) with SNHL. craniostenosis and exophthalmos associated with external and middle ear abnormalities. middle or internal ear deformities. Autosomal dominant 1. Usher’s syndrome. Below are those we consider to be the most important: Autosomal recessive 1. Sensorineural deafness may be a hereditary degenerative deafness where there is progressive loss of hearing. maxillary hypoplasia. maxilla and mandible. typically in late childhood in subjects with a previously normal cochlea in both structure and function (the abiotrophies). . 5. 3. Prolonged electrocardiographic Q-T interval and SNHL. Retinitis pigmentosa. Most of these are non-syndromic and many are abiotrophies. Apert’s syndrome. Retinitis pigmentosa and SNHL. conductive or mixed and may occur in isolation or with other congenital abnormalities (the syndromes). Hypoplasia of the malar bones. Jervell and Lange-Nielson syndrome. There may be external. Hypoplastic mandible and maxilla. Congenital fixation of the stapes footplate. Refsum’s disease. Crouzon’s disease.

. Secondary to intrauterine disease (a) (b) (c) (d) Infections: rubella. 4. The ventral arch cartilage forms the mandible (1st arch) and the hyoid bone (2nd arch). mastoid pneumatization absent and there is a significant risk of one of the cochlear dyplasias. The bony labyrinth is normal. The external and middle ear anomalies are classified into three groups: 1. The stapes is usually functionally normal. Major aplasia. 2.g. maternal diabetes mellitus. Scheibe dysplasia. from the dorsal end of cartilage within each arch. Classification of congenital sensorineural deaf ness 1. Anomalies of structures associated with these arches gives rise to multiple deformities. The external auditory meatus is narrow. 2. There is usually microtia with external ear canal atresia and fixation of an abnormal malleus and incus. the tympanic cavity small. These arches form the pinna (mesoderm and ectoderm). Ototoxic drugs (see ototoxicity chapter). The most severe ‘dysplasia’ (more correctly this is an aplasia) with agenesis of the labyrinth and total sensorineural deafness. There are few hair cells and the saccule is collapsed. The external ear may be atretic. Stapes surgery is difficult because of limited access and there is an increased risk of a perilymph gusher so that a small fenestra technique is recommended should stapedectomy be attempted. (b) Deafness appearing in childhood: Deafness alone. Hereditary (a) Deafness present at birth: Deafness alone. Metabolic disorders: e. but there is maldevelopment of the membranous labyrinth. The bony labyrinth is normal. Hearing loss is severe. bony labyrinth (mesoderm). membranous labyrinth (ectoderm) and. toxoplasmosis. low birth weight. cytomegalovirus.g. the ossicles (mesoderm). Michel’s deformity. Bing-Siebenman dysplasia. the pinna either normal or with a minor deformity and there may be ossicular fixation. 3. They comprise: 1.CONGENITAL HEARING DISORDERS 59 The dysplasias The dysplasias describe four congenital abnormalities of the cochlea and often occur as a component of the hearing syndromes. for example Treacher-Collins and PierreRobin syndromes. the tympanic membrane functional. Minor aplasia. syndromes associated with deafness. 3. especially in the high tones. hypoxia. There are islands of residual hearing. but the stria vascularis has alternating regions of aplasia and hypoplasia. syndromes associated with deafness. Mondini’s dysplasia. Congenital conductive hearing loss The external ear canal develops from the first branchial cleft lying between the first and second branchial arches. Perinatal disorders: e. Only the basal coil of the cochlea is present and the semicircular canals may be absent. congenital syphilis. usually of the stapes. 2. Major aplasia/atresia. hence its synonym cochleosaccular dysgenesis. premature delivery. hyperbilirubinaemia.

60 OTOLARYNGOLOGY Classification of congenital conductive hearing loss 1. Recent developments There have been significant advances in the genetic basis of hearing loss. Further reading Lusting LR. otosclerosis. 1998. 3. Miscellaneous conditions. Cystic fibrosis. (a) Present at birth: e.g. and Tunnel DE. Congenital cholesteatoma. Crouzons disease. Waardenburg syndrome type 1 to the long arm of chromosome 2 and the branchio-oto-renal gene. The Jervell and Lange-Nielsen gene has been mapped to the short arm of chromosome 11. osteogenesis imperfecta. cleft palate. 6:360–367. Many non-syndromic genes are now mapped as are several genes coding for syndromic deafness. Mapping genes of non-syndromic deafness is difficult and relies on finding large families who have a significant number bearing the trait. Apert’s syndrome. Ideally the transgene insert will include an inducible promoter that will allow turning gene expression on and off according to need. Sensorineural hearing loss in children. The introduction of a correct. efficient vector to deliver the gene to a spiral ganglion hair cell and which produces long term transduction and a minimal immune response is still being researched. 2. Mutant genes coding for deafness at birth will be more difficult to resolve and will necessitate fetal gene therapy. Mapping a gene gives rise to the possibility of gene transfer. Fibrous dysplasia. Hereditary abnormal external or middle ear. has been mapped to the long arm of chromosome 8. Presently a safe. appropriate surgery or/and rehabilitation. depending on the cause. . Current Opinion in Otolaryngology & Head and Neck Surgery. (b) Appearing in childhood: e. Goldenhar’s syndrome. Pierre-Robin syndrome.g. These babies and those suspected of having one of the syndromes or dysplasias should be referred to a paediatric otologist or audiologist who will be able to investigate the suspected hearing loss and institute. Down’s syndrome. non-mutated copy of a mutated gene coding for a deafness genotype has recently been shown to correct the phenotype so that when hair cell specific vectors are available. Congenital disorders predisposing to glue ear. a homologue of the Drosophilia absent eye gene. Easily identifiable regions of chromosomes (markers) are inherited and the ability to map a non-syndromic gene depends on the proximity of this gene to a marker so that the two are inherited together and in this way a linkage map is generated. Kartageners syndrome. it may be possible to extend gene therapy to the abiotrophies. Management The congenital hearing loss may be suspected at birth because of the family history. Treacher-Collins syndrome.

Hearing aids. p. Paediatric hearing assessment. 1999. 117. 53. p. Recent progress in hereditary hearing loss.CONGENITAL HEARING DISORDERS 61 Morrell RJ. Cochlear implants. 239. p. 228. 7:259–265. Related topics of interest Ototoxicity. Current Opinion in Otolaryngology & Head and Neck Surgery. . p.

bony dorsal augmentation using a rib graft (not a straight graft but it can be osteotomized). A dilemma in rhinoplasty surgery is what graft to use when augmentation is necessary. but it is usually possible to correct specific defects so that the nose no longer brings attention to the face. This however depends on the dimensions of the upper. hair transplantation and rhytidectomy. so the patient will have a realistic expectation of the likely operative result. pinnaplasty. under.or overprojected tip. sleep apnoea.COSMETIC SURGERY This chapter is confined to a description of rhinoplasty. The nasolabial angle should be about 90° in males and 110° in females. facial reanimation. iliac crest (the bone here is cancellous) or a silastic implant will cover most situations. In the USA there is a current vogue for external rhinoplasty which has the advantage of visualizing directly the osteocartilaginous vault during surgery. mid and lower thirds of the face. Functional: nasal obstruction. It is not disputed however that a nose should be straight and have a uniform dorsal width from nasion to the tip. Cartilaginous augmentation by manoeuvring quadrate cartilage into a new position or using conchal cartilage with perichondrium attached. There is no singly perfect shape. the thickness of the nasal skin and the race of the patient. Technique Most rhinoplasty surgery consists of a basic technique comprising nasal dehumping. polly beak. 2. Again there is no ideal graft that fits all scenarios. It is important that the patient states specifically what they dislike about their nasal shape and for the surgeon to state exactly what deformities he is aiming to correct. Cosmetic: dorsal hump. It is often the case that it is not possible to make an ugly nose pretty. medial and lateral osteotomies with in-fracture and excision of a cephalic rim of lower lateral cartilage if the tip requires cephalic rotation. Rhinoplasty Indications 1. . snoring. Much is written about the ideal nasal size and shape. too wide or too narrow dorsum. dorsal saddle.

Facial nerve grafting The reinnervation procedure chosen will depend on the site of injury and the surgeon’s personal preference. Mustarde technique in which the antihelix is folded and kept in position with mattress sutures. The two common techniques are: 1. Facial reanimation Surgery to produce improved facial symmetry after a facial nerve palsy should not be undertaken until the surgeon is sure there will be no spontaneous improvement. Most surgeons will have their own modification of one of these techniques which works well for them (e. 2. The only indication to remove the dressing is increasing aural pain. a cable graft using sural or great auricular nerve should be attempted. It is unusual for the head dressing to be too tight and then the main symptom will be a persistent headache. This may be immediate if trauma. Direct apposition of the nerve ending using monofilament 9–0 nylon suture material should be attempted only if it is possible to avoid tension on the anastomosis. Many surgeons state that it is better not to apply a head dressing than apply one which is inadequate. Anterior conchal scoring technique described by Stenstrom allowing the cartilage to curl back to form an antihelix without suturing. slightly less satisfactory facial tone occurs. which usually indicates that a subperichondrial haematoma has formed due to inadequate pressure. there may be an overlarge conchal bowl in addition to an absent antihelix) to become apparent. as the trauma to the ear from repeated redressing will predispose to infection or haematoma.g. hypoglossal to facial or accessory to facial nerve anastomosis are the options. The latter uses the larger branch to trapezius muscle with little loss of shoulder movement or strength. Cotton wool should support the post-auricular region and fill the conchal bowl. . surgery should be performed before infant school to prevent ridicule. in order to preserve tongue movement. the operated ear being splinted and protected. Ideally. An important and often neglected portion of the procedure is the pressure dressing. has caused an immediate and total palsy suggesting nerve transection. and a firm head dressing applied in such a way that it will not slip until it is removed 7–14 days later.g. When only half the width of the hypoglossal nerve is anastomosed to the facial trunk. One year post onset is arbitrarily taken as the minimum time to allow the nerve to recover maximum function after injury or following attempted reinnervation.COSMETIC SURGERY 63 Pinnaplasty Most surgeons wait until the patient is at least 3-years-old so that the ear is not too small to manipulate and for the full deformity (e. For more proximal injuries such as those occurring after acoustic neuroma surgery. Reliable results are obtained only if anastomosis is attempted within one year of the onset of a palsy whereas the standard procedure is reliable when used up to two years after facial palsy. Otherwise. either external or iatrogenic. thinning the region of the antihelix fold in the Mustarde technique with a diamond drill to reduce cartilage tension and to allow a more natural curve).

A small percentage of patients who develop excessive alopecia including the fringe areas. Eyelid procedures A gold weight implant positioned over the tarsal plate and centred at the junction of the medial and middle third of the upper eyelid has been used for more than thirty years to rehabilitate the eyelid following facial nerve paralysis. They are placed into wounds created by needles or specifically designed small knife blades to create a 1 cm zone of single hair grafts. which can occur early or several years after implanting. The main complications are infection and haematoma in the early postoperative period and extrusion. To minimize extrusion rates it is recommended a drill hole is fashioned through the implant and this used to attach it to the tarsal plate by a nylon or prolene suture. Most series have reported a high rate of extrusion and infection compared to fascia lata. The commonest form of hair loss is androgenic alopecia (AA) which may present as male or female pattern AA or diffuse AA. or an incisional slit. Micrografts are single hair grafts. The technique comprises placing the muscle sling lateral to the fascia overlying the muscles of facial expression to avoid the underlying facial nerve twigs. micrograft. The material is pre-stretched and so postoperative sagging is unusual in contradistinction to fascia lata. Rhytidectomy The original facelifts were the equivalent of modern minilifts in which an ellipse of skin is excised at or in the hairline and the tension of closure used to pull the facial skin taught. scalp extenders and flaps now allow the creation of a virtually undetectable hairline and yield results not possible just five years ago. usually placed along the frontal hair line to give a natural feathered appearance. Sterile 1 mm thick Gore-Tex Soft Tissue Patch can be used for static suspension in those unsuitable for dynamic suspension. Minigrafts (3–5 hairs per graft) are placed into holes created by a punch or laser. It improves the symmetry of the face at rest and on voluntary smiling in those with a permanent facial paralysis but does not improve lagophthalmos. Implants of different weights are taped to the upper lid preoperatively to determine the correct weight to just allow closure without ptosis. Up to 1000 grafts may be taken in a single session. Most patients with AA are candidates for some form of hair replacement procedure. Male pattern alopecia is progressive and this may compromise long term results. Several sessions of mini and micrografts 3 or 4 months apart may be required to achieve a satisfactory result. GoreTex being used when necessary to lengthen the sling. may not be suitable for any form of surgery. The strips are then divided into micro or minigrafts. Hair transplantation Modern techniques such as minigraft. . Grafts are harvested from the dominant fringe using special multiblade knives which allow the harvesting of multiple strips of hair-bearing scalp simultaneously. The material is attached to the zygomatic arch and the orbicularis muscle to elevate the mid-facial and perioral region.64 OTOLARYNGOLOGY Dynamic and static suspension Dynamic suspension comprises transposition of the temporalis muscle to the submucosa or the orbicularis oris muscle in close proximity to the angle of the mouth. It can be compli mentary to facial nerve cable grafting or hypoglossal-facial anastomosis. In some centres only the middle section of the muscle is transposed. scalp expanders.

92. Hypoglossal-facial nerve anastomosis. Reconstructive surgery. 1991. p. Harrison DH. Further reading Kunihiro T. p. deep plane facelift and the composite and extended SMAS facelift. Rhytidectomy: past. 1993. Archives of Otolaryngology Head and Neck Surgery. 119:378–382. Facial nerve palsy. This technique had the disadvantage of occasionally causing skin necrosis or a wide scar due to increased skin tension on the suture line. Kanzaki J. allowing elevation up to the midline. In the 1970s a superficial muscle and aponeurotic system (SMAS) was described and most modern facelifts involve elevating the SMAS and fat to provide a more effective and longer lasting result. 1992. British Journal of Plastic Surgery. present and future. Campbell AC and Shumrick KA. Current Opinion in Otolaryngology and Head and Neck Surgery.COSMETIC SURGERY 65 Anterior subcutaneous elevation in a plane superficial to the fascia of the muscles of facial expression to avoid injuring the facial nerve became widespread in the 1970s. 45:460–464. 267. Acta Otolaryngologica. Journal of Neurosurgery. O-Uchi. Related topics of interest Nasal trauma. Drucker C. p. May M. Scamp T. 1997. 5:234–242. 77:51–54. 177. Pickford MA. 1992. Ebersold MJ. Quast LM. Long-term results of spinal accessory nerve-facial nerve anastomosis. subperiosteal facelift. the details of which may be found in operative texts. The technique has been further developed to the present day multi-directional facelift. . Temporalis muscle for facial reanimation: A 13-year experience with 224 procedures. 487: 80–84. Morbidity after gold weight insertion into the upper eyelid in facial palsy.

. for example after adenoidectomy or submucosal diathermy. The patient must be taken home by an adult in a car or taxi on discharge. In a general ward booked admissions may be blocked by emergency admissions. mild-to-moderate systemic disturbance caused either by the condition to be treated surgically or other pathophysiological processes. An example of a guideline sheet is shown in appendix 1 and can be modified according to the preferences of each unit. The home should be within a 20-min drive of the hospital if the patient is at risk of a primary haemorrhage. theatres and recovery area. Patient selection The patient may be admitted into either a self-contained day surgery unit with its own admission suites. the patient has no organic. for example non-insulin-dependent diabetes mellitus or essential hypertension). biochemical or psychiatric disturbance and the pathological process for which surgery is to be performed is localized. and legal documents should not be signed during the first 24-h postoperative period. guidelines for surgeons regarding medical suitability for day case surgery. Patients with a body mass index (BMI) greater than 35 are unsuitable. No mechanical device should be used nor cooking undertaken. Operations likely to take longer than 60 min are unsuitable because of the slow speed of recovery from general anaesthetic. and patients should normally be of ASA I or ASA II status (the American Society of Anesthesiologists classification of physical status: class 1. this is an expensive option because the ward is not closed at night or at the weekend. physiological. As a rule an upper age limit of 75 is recommended although older patients with a low biological age should be considered. Driving is not advised within 48 h of a general anaesthetic. when alcohol is also forbidden.DAY CASE ENT SURGERY Definition An ENT surgical day case patient is one admitted for operation on a planned non-resident basis but who requires facilities for recovery. wards. An adult must be available to supervise the patient during the evening and first night. Full admission procedures and records are required. by collaboration between anaesthetists and physicians. or less desirably a day case ward or unsatisfactorily a general ward. or class 2. A telephone must be accessible so that the hospital can be contacted in an emergency. Every day surgery unit should produce. which therefore excludes those operations and procedures undertaken in the outpatient or accident and emergency department.

Revised edition. submucosal resection of the nasal septum. Disadvantages • Limited care available to the patient after discharge. London: The Royal College of Surgeons of England. Removal of impacted wax or foreign bodies. Early mobilization. skin tags. with its own play area and parental waiting area. Selected patients requiring laser therapy. They should have their own designated area away from adult patients. Excision of accessory auricles. Head and neck. examination under anaesthetic (EUA) and biopsy of the laryngopharynx and oesophagus provided there is no risk to the airway. Anaesthetic administered allows rapid recovery. bilateral antral puncture. Advantages • • • • • • • Lower costs. myringotomy with or without grommet insertion. limited intranasal polypectomy. sub-mucosal diathermy of the inferior turbinate.DAY CASE ENT SURGERY 67 Paediatric surgery Special facilities for children are required. limited functional endoscopic sinus surgery. Increased efficiency. Reduced in-patient theatre workload. electrocautery of the nasal septum. if needed. A preadmission visit allows familiarization. Ear. Surgery time should be less than 1 h. septoplasty. • In-patient admission. 2. Appendix 1 Selection criteria All patients should be ASA I or II and ambulant. Reduced disruption to life. aural polypectomy. It is permissible to have a children-only operation day in a day surgery unit or day case ward if the required facilities are present. Adenoidectomy. . 3. for example vocal cord polypectomy or nodule excision and laser excision of small tongue lesions. 1992. Reduction of nasal fractures. must be arranged at short notice. Nose. preauricular sinuses. tonsillectomy (controversial). Wedge excision biopsy of pinna lesion. Other indications include the division of tongue tie and lymph node excision biopsy. Further reading Report of the Working Party on Guidelines for Daycase Surgery. The children’s area should be staffed by paediatric-trained nurses. Less psychological preparation required. Appropriate Procedures 1.

ECG satisfactory <12months CVS MI less than 3 years ago Unstable angina Symptomatic heart disease Ventricular arrhythmia Pacemaker due to 2nd or 3rd degree heart block Stable angina or controlled atrial fibrillation with satisfactory ECG and serum urea and electrolytes Hypertension BP < 170/100 BP > 175/105 Respiratory disease COAD or emphysema but: (i) able to climb two flights of stairs (ii) unable to climb two flights of stairs Asthma Well controlled on inhalers Previously hospitalized or taking systemic steroids Diabetes Insulin dependant NIDDM and BM stix < 11 and ECG satisfactory Neurological disease Restriction of normal activity or CVA within past 1 year Not restricting normal activity Epilepsy Poorly controlled Well controlled (no seizures during previous 1 year) Hiatus hernia Consider H2 blockers before surgery Bleeding disorder Drug history Systemic steroids within previous 3 months or cardiac drugs other than antihypertensives or taking MAO drugs Diuretics but satisfactory ECG and serum urea and electrolytes Anaesthetic problem Difficult intubation Malignant hyperpyrexia ITU admission Blood relative died or had any of above Minor (e.68 OTOLARYNGOLOGY No escort home No adult overnight Lives > 1 h away Age 60–75 years but fit.g. nausea or very slow to arouse) Social circumstance Unsuitable Suitable Unsuitable Unsuitable Suitable Suitable Unsuitable Suitable Unsuitable Suitable Unsuitable Unsuitable Suitable but instruct no medication on day of surgery Unsuitable Suitable Unsuitable Suitable Suitable Unsuitable Refer for assessment Suitable Refer for assessment Suitable .

It may also occur in adults. Prophylaxis In recent years efforts have been focused on the prevention of HIB infections. Inspiratory stridor then occurs. with a peak incidence between the ages of 3 and 4. but predominantly the loose connective tissue of the epiglottis. which may be attributed to the new conjugated HIB vaccine approved for administration to 2-month-old infants. influenzae in early childhood may later be followed by a type III Arthus hypersensitivity reaction which would account for the rapid onset of epiglottitis. Haemolytic streptococci. This can also occur if the child becomes distressed and starts to cry. so nothing that may be frightening should be allowed. A critically ill. Epiglottitis is usually seen in children between the ages of 2 and 6 years. The provisional diagnosis is made on the history and the examination of the child. flushed appearance and a high temperature (38–40°C). Attempts to depress the tongue or indirect laryngoscopy should not be undertaken to confirm the diagnosis as this can precipitate laryngospasm. . but this is not invariable. The inflammation and oedema will rapidly progress to cause muffling of the voice and respiratory obstruction. Aetiology Haemophilus influenzae type B (HIB) is the usual causative organism. Quite why the infection has a predilection for the epiglottis is not clear. In children under the age of 2 years Haemophilus tends to cause meningitis. There is an acute inflammation of the larynx which affects all the supraglottis. It has been suggested that previous contact with H. breathless child may then present to the casualty department having a toxic. There seems to have been a decline in new cases over the last few years. The child will usually sit up and lean forward dribbling saliva. pneumococci and staphylococci have also been isolated. Clinical features The disease may present at any time of the year but is more common in winter. Initially the child usually complains of a sore throat and pain when swallowing.EPIGLOTTITIS Acute epiglottitis is an uncommon but dangerous bacterial infection of the throat. especially in adult cases.

et al. . A parent should be present and at all times the child is talked to and reassured. Westmore RF. As the epiglottic oedema settles an increasing leak around the endotracheal tube is expected. This is usually possible within 48 hours. Acute epiglottitis—aetiology. This should then be replaced with a nasotracheal tube as they are more readily tolerated and more securely fixed. extubation can be considered. Some surgeons advocate the use of corticosteriods before decannulation to help reduce oedema caused by the tube. 1327–1337. Paediatric intensive care. 1993. Rarely. especially lying down. In the early case a lateral soft-tissue neck radiograph may confirm a swollen epiglottis but is not essential and may be dangerous. An intravenous line is inserted for fluid replacement and antibiotic therapy. and all investigations should be delayed until this is secure. The child is allowed to remain in an upright posture as sudden changes in position. a tracheostomy may be necessary. antibiotics and humidified inspired gases. The taking of a radiograph should never be done if epiglottitis is suspected and there are already signs of respiratory difficulty. International Journal of Otolaryngology. Marsh R. 19:441–445. Because of the side effects of chloramphenicol. and if intubation fails a rigid bronchoscope should be inserted immediately and subsequently replaced with an endotracheal tube. Direct laryngoscopy should be performed to establish the diagnosis and to pass an endotracheal tube.70 OTOLARYNGOLOGY Investigations Maintenance of the patient’s airway is the primary consideration. may result in airway obstruction. Intravenous access is not attempted and the child should be moved to a quiet induction area with adjacent operating facilities. Kessler A. The current choice of antibiotic is chloramphenicol (100 mg per kg body weight per 24 hours) as up to 30% of Haemophilus strains are resistant to ampicillin. A gentle inhalation induction using sevoflurane and oxygen is preferred.) Paediatric Anaesthesia. The oxygen saturation is closely monitored with pulse oximetry. New York: Churchill Livingstone. The sedated child is transferred to a paediatric intensive care unit for rehydration. 2nd edn. An appropriately sized orotracheal tube is inserted to immediately restore the airway. In: Gregory GA (ed. 1989. Follow-up and aftercare There is usually a prompt response to treatment with fluid replacement and antibiotics. third generation cephalosporins are an alternative. Once the child is afebrile and appears well. Once an airway has been established swabs are taken from the epiglottis and a blood culture is performed. There may be difficulty establishing an endotracheal airway. Furthermore. Oedematous aryepiglottic folds and a cherry red epiglottis are characteristic signs of the disease. A nasogastric tube should be inserted for feeding. Childhood epiglottitis in recent years. An experienced paediatric anaesthetist and otolaryngologist should be in attendance. When the child is asleep. Clinical Otolaryngology. Further reading Hugosson S. no child should be sent for a radiograph without the continuous presence of someone skilled in paediatric intubation. Pascucci RC. Treatment The first requirement of treatment is to safeguard the airway. epidemiology and outcome in a population before large scale Haemophilus influenzae type b vaccination. 1994. 25:155–162. the parent is shown from the room.

p.EPIGLOTTITIS 71 Related topics of interest Paediatric airway problems. 237. . Paediatric endoscopy. 232. p.

sinuses and nasopharynx). steroid nasal sprays). sphenopalatine. . superior labial). Diseases of the blood (haemophilia. General causes • • • • • Anticoagulants (warfarin. Hypertension. Neoplastic (tumours of the nose. Endocrine (menstruation. pneumonia). 2. Traumatic (fractures. especially when bleeding is brisk. Local causes • • • • • • • Idiopathic (85%). It is important that nursing support is available in this situation to assist with management of the patient. which may be more to do with its comparatively exposed position in the anterior part of the septum than the fact that this is where the vessels anastamose. aspirin). Inflammatory (rhinitis.EPISTAXIS Aetiology 1. latrogenic (surgery. Blood vessels involved The upper parts of the nose are supplied by branches from the internal carotid artery (anterior and posterior ethmoidal arteries) and the rest from branches of the external carotid artery (greater palatine. Familial haemorrhagic telangiectasia (Osler-Rendu-Weber). Environmental (high altitude. nose picking). sinusitis). Clinical assessment Always make sure that the patient is not in shock. Protect the patient’s clothing and your own with an apron. foreign body. but the instigation of immediate resuscitation is not usually necessary. pregnancy). Little’s area (Kiesselbach’s plexus) is the commonest site of bleeding. air conditioning). Raised venous pressure (whooping cough. leukaemia).

Take a full history and on examination try to localize the area from which bleeding is arising and any specific bleeding points. 5. If nasal packing is required. Surgical intervention 1. Hereditary haemorrhagic telangiectasia A specific problem in the management of epistaxis (and favourite examination topic) includes hereditary haemorrhagic telangiectasia or Rendu-Osler-Weber disease. The artery is surrounded by periosteum about 2. 4.5 cm deep to the orbital rim just above the level of the medial canthus and is readily controlled by clipping. The bleeding is usually stopped by one of the following methods: • • • • Pressure on the nostrils (can be supplemented with ice-cold packs and sucking ice cubes). diazepam) will relieve the patient’s anxiety. Embolization of vessels under radiographic control with gel sponge or beads is advocated in some centres. as well as telangiectases on . and sinusitis. Each tortuous branch is clipped in turn. Further surgery is indicated only on the rare occasion when haemorrhage is not controlled by packing and cautery. Endoscopic approach. especially the tongue. For exposure and ligation of the sphenopalatine artery.g. 6. systemic antibiotics should be given to prevent otitis media from Eustachian tube blockage. but because of the risks involved (e. merocel). Local cautery (chemical or electrocoagulation). Management The aims are to arrest the haemorrhage and to treat the underlying cause. Anterior nasal packing (paraffin gauze.v. Brighton balloon). Packing of the postnasal space (gauze. External carotid artery ligation Ligation of the external carotid in the neck may be needed if maxillary artery clipping is unsuccessful. above the middle turbinate. or if a severe epistaxis recurs. Submucosal resection 2. Examination under general anaesthetic may become necessary if the above measures fail to allow better identification of the bleeding site and more effective cautery and packing. clotting studies and blood for group and cross-match if necessary. Patients with this are easily recognized by red spots on the lips and the mucous membrane of the mouth. The artery is encountered in the pterygopalatine fossa and teased away from the fat pad. the antrum entered and a window made in the posterior wall of the sinus. white cell count and platelets). Investigations should include a full blood count (FBC) (check Hb. Anterior ethmoid artery dipping is required for uncontrollable bleeding from the upper part of the nose. 3. Ligation or dipping of the maxillary artery in the pterygomaxillary fossa. Foley’s catheter. cerebrovascular embolus) has not been fully accepted. The approach to the anterior ethmoidal artery is via a medial orbital incision with lateral displacement of the upper orbital contents.EPISTAXIS 73 and wear gloves. A Caldwell Luc incision is made. BIPP. Calm reassurance coupled with sedation (i. If the bleeding has been significant start an intravenous infusion.

Further reading McGarry. lining mucosa with placenta or split skin grafts and laser therapy (argon or Nd-YAG). or arteriovenous malformations in the lungs. radiotherapy. Follow-up and aftercare This depends on the cause and severity of the bleeding. Endoscopic ligation of the sphenopalatine artery. The condition may be complicated by the presence of lesions in the gut.74 OTOLARYNGOLOGY the face and nose. . which may bleed. Clinical Otolaryngology. 84. Related topic of interest Examination of the nose. sclerosants. other therapies include oestrogens. p. The patient is asked if there has been any further bleeding and their haemoglobin levels checked before discharge. but all patients who have required admission and treatment in hospital should be reviewed in the outpatient department. In addition to repeated local treatment.

Access to evidence is improving with the recognition for the need of a ‘chief knowledge officer’ to dissemninate information to the rest of the organization. and training. 3 . difficulties in applying evidence due to: • • • • • poor access to best evidence and the need for validated guidelines. resource allocation. as well as taking note of systemic reviews that have been performed by institutions such as the Cochrane Centre and through the medium of well drawn-up guidelines. . difficulties in developing evidence-based clinical policy. performance feedback and empowerment have all been shown to be effective but need resourcing. Incentives such as financial reward. finding and evaluating all relevant research evidence. The first two points concern the equipping of clinicans and managers with critical appraisal skills. and reaching a conclusion about which option would have the greatest liklehood of effectiveness’. education. Poor compliance to treatments by patients. there is also the need for changes in clinical behaviour that are necessary to ensure the successful implementation of guidelines. the size and complexity of the research required. A change in behaviour can be reinforced by providing incentives to work in a different way.EVIDENCE BASED MEDICINE P. incentives that are locally negotiated and agreed are more likely to succeed than those imposed from above. Apart from the barriers identified. During the 1990s it was defined as: ‘medical practice in which clinical problems are addressed by formulating clearly defined questions. Problems There are many reasons cited for the reluctance to embrace EBM into daily clinical practice: 1 . leading to a behavioural change in those required to follow a different way of working. The heterogeneity of the patient population. to assess the research evidence. As with the pocess of obtaining the commitment of stakeholders. organizational barriers. poor continuing educational programmes. 2 .Bradley Definition The term ‘evidence based medicine’ (EBM) was first used in the 1980s at McMaster University in Canada. A veriety of interventions are required.J. patients and employers.

evaluating our own resulting performance. with level la being evidence obtained from meta-analysis of randomized controlled trials (the gold standard) to level 4 which is the evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities. but in particular from patient centred research into the accuracy and precision of diagnostic tests. The steps comprise: • • • • • rephrasing our problems or information needs into answerable questions. therefore. rehabilative and preventa-tive regimens. • Treatment questions—ask what the efficacy of a specific treatment is commonly compared to placebo. 1. Clinical evidence EBM is the conscientious. EBM divides clinical questions into a number of types. EBM includes audit as well as consideration of the external evidence. and the efficacy and safety of therapeutic. which may be from basic sciences. • Harm and aetiology questions—the risk of harm arising out of treatments or interventions or about the association between a factor and a medical condition (smoking and lung cancer). with no direct comparison of treatments. the steps in answering them are the same. applying the evidence to pure practice. • Prognosis questions—outcomes. the power of prognostic factors. • Diagnostic test questions—the accuracy of diagnostic or prognostic tests. being able to appraise the evidence we find for validity and usefulness. The levels of evidence are classified as 1–4. Its practise requires the integration of individual clinical expertise with the best available clinical evidence from systematic research. What is the evidence? . efficiently tracking down the best evidence with which to answer them. The BAO-HNS will work with these groups and will welcome the additional contribution being made by the National Otolaryngological Trials Office (NOTO) in Newcastle and by the Cochrane ENT Working Group in Oxford. Interpretation In essence. The best available clinical evidence refers to clinically relevant research. EBM is simply a method for identifying and interpreting the relevant research data to help with the questions faced in our clinical lives. The National Services Frameworks will rationalize this process in the UK through the National Institute for Clinical Excellence (NICE) with external monitoring being provided by the Commission for Health Improvement (CHI). The feedback loop implied by the last two points indicates the relationship between audit and EBM.76 OTOLARYNGOLOGY Clinical governance The introduction of Clinical Governance with the expectation that the use of guidelines and audit will improve patient care. explicit and judicious use of current evidence in making decisions about the care of individual patients. Regardless of the type of question asked.

suggested that there is poor evidence base for our specialty if one regards randomized controlled trials as the gold standard. 1:27–34. Finally. Is the evidence valid? 3. Armstrong MWJ. Which clinical studies provide the best evidence? British Medical Journal 2000. asprin and digoxin are also difficult to randomise against a placebo. Maran AGD. 321:255–256. In many cases. 268:2420–2425.EVIDENCE BASED MEDICINE 77 2. but they do support a flexible approach in which a randomized controlled trials and observational studies have complementary roles. 1997. Conclusion A review of the published literature during 1990–1994 in five major general otolaryngological journals. There are several reasons for not performing RCTs in surgery. Edinburgh: Churchill Livingstone. there are important practical difficulties in performing RCTs of surgical operations that do not exist with most medical treatments. 22:483–484. High quality observational studies may extend evidence over a wider population and are likely to be dominant in the identification of harms and when randomized controlled trials would be unethical or impractical. Medical management of appendicitis against surgical appendicectomy. Is there evidence base for the practice of ENT surgery? Clinical Otolaryngology. The second obstacle to trials of operations is the difficulty that arises when attempting to compare surgical against non-surgical treatments. What are general practitioners’ attitudes towards evidence-based medicine. First history. Rosenberg W. JAMA. 1992. Clinical guidelines for otorhinolaryngology. . British Medical Journal. Once a treatment is accepted as the standard for the management of a given condition. Moloney NC. Richardson WS. and are these changing? Journal of Clinical Excellence. Clinical Otolaryngology. Barton S. Haines A. though this can sometimes be done with an imaginative trial protocol. Haynes RB. Evidence-based medicine: how to practise and teach EBM. 1997. it is difficult to achieve the level of uncertainty (‘equipoise’) about its benefit required to persuade clinicians to test it again against a placebo. Haynes B. Further reading Patterson JV. 317: 273–276. Sackett DL. Is the evidence important? 4. It is difficult to blind patients and staff to the operation performed. 1997. the benefits of the treatment are so great and obvious that such a trial would be clearly unethical. one UK and the other four USA based. Evidence medicine: a new approach to teaching the practice of medicine. particularly their failure to conduct randomized control trials (RCTs). This situation is not confined only to surgery: old drugs such as morphine. If so how? Problems Surgeons have been severely criticized for their failure to apply EBM in the past. Barriers and bridges to evidence based clinical practice. Ah-See K. 22:152–157. Stewart-Brown SL. Bradley PJ. Should we change our practice because of the new evidence. 1999. Studies more recently do not justify a major revision of the hierarchy of evidence. Evidence-Based Medicine Working Group. 1998.

It has no threshold and increases in amplitude with the stimulus intensity. the tests are not truly objective as a tester will have to interpret the complex tracings obtained from the procedure. However. No conscious response is required from the patient. electrical signals are produced by various parts of the auditory system from cochlea to cortex.EVOKED RESPONSE AUDIOMETRY In response to sound stimulation. • Brainstem electrical response. In practical terms three main responses can be recorded: • Electrocochleogram. This signal is produced by the hair cells and resembles the pattern of the basilar membrane vibration. Technique The patient lies comfortably in a soundproof room. As the amplitude of the evoked electrical response is small relative to the body’s background electrical noise. The test signal can be produced using a loudspeaker or headphones (especially if acoustic conditions are less than ideal). The cochlear microphonic. a variety of filters and an averaging computer are used. so the tests are less open to the bias in results which arise in those tests requiring patient cooperation. A ground electrode is attached to the patient’s forehead and a reference electrode to the ipsilateral mastoid. Physiology The signal recorded by ECochG is described as a compound action potential. Its polarity follows that of the test signal. . It is diphasic at threshold and has a signal latency which decreases with increasing signal intensity and is made up of three parts: 1. Evoked response audiometry (also called electric response audiometry) is a technique designed to measure these signals. • Cortical electrical response. Wideband clicks and high-frequency tone bursts are the usual stimulating test signals. The active electrode is usually a trans-tympanic needle placed on the promontory (canal electrodes may be used but give a less satisfactory signal) after preparation with local anaesthetic. Electrocochleography Electrocochleography (ECochG) aims to measure the signal produced by the cochlea and cochlear nerve in response to acoustic stimulation.

Clinical indications High-resolution computerized axial tomography and MRI have superseded many older otological investigative techniques and consequently removed many of the indications for EcochG. because of their size. The action potential. The accuracy of the I-V latency has been improved by combining ECochG with BERA to aid the detection of wave I. The results are analysed by looking at the absolute values for various wave latencies. Investigation of suspected Menière’s disease. and comparing results between the two ears. Physiology The signal recorded by BERA is made up of a five-wave complex. which is thought to represent successive synapses in the auditory pathway as follows (Jewett classification): . 3. but the filter and time window settings are altered. It is therefore important that the patient stays as still as possible and. Typically there is an increase in the summating potential with a normal action potential in the affected ear. It has a threshold. several thousand responses are analysed as opposed to hundreds in ECochG. is independent of signal polarity and exhibits adaptation. It is therefore particularly useful in very young children or those with neurological disorders. It is also produced by cochlear hair cells and does not adapt in response to high stimulation rates. The signals are usually presented using headphones to allow monaural testing. The hardware and test signals used (wideband clicks and high-frequency tone bursts) are identical to those used for EcochG. ECochG is the most accurate of the electrical response audiometric techniques for threshold testing and can predict to within 5–10 dB of the psychoacoustic threshold at 3–4 kHz. the reference electrode to the ipsilateral (test ear) mastoid process and the ground electrode to the contralateral mastoid process. 2. Technique The patient reclines on a bed or couch.EVOKED RESPONSE AUDIOMETRY 79 2. 3. As the evoked responses are so small they are easily masked by other neuromuscular signals. forehead and vertex. the so-called I-V latency. particularly the search for an acoustic neuroma. Unfortunately. This is the depolarization of the cochlear nerve and is similar in many respects to any neural depolarization. In current practice ECochG may be used for: 1. The summating potential. The active electrode is attached to the vertex. Brainstem electrical response audiometry Brainstem electrical response audiometry (BERA) records the signals produced in the brain stem detected by electrodes placed over the mastoid. Threshold testing. The electrodes are surface electrodes. Intraoperative monitoring during surgery around the inner ear and internal meatus. it gives little low-frequency information (< 1 kHz) but has the advantage of being a monaural test technique and is relatively resistant to minor muscular contractions which would preclude brainstem response audiometry and is unaffected by general anaesthetic. This complex potential is derived from a variety of sources but in essence is an alteration of the electrical potential baseline (usually negative) in response to a sound stimulus.

useful results are virtually impossible if the affected ear has very poor thresholds (> 70 dB). Technique The patient sits comfortably in a chair.80 OTOLARYNGOLOGY Wave I II III IV V Site of generation Cochlear nerve Cochlear nucleus Superior olive Lateral lemniscus Inferior colliculus Latency (msec) 2. One of the main indications for BERA is to exclude an acoustic neuroma (or other brainstem tumour) in patients with asymmetrical hearing loss. Threshold is taken as the point at which the V-potential disappears.0 3. Acoustic neuroma.4 msec when compared with the normal ear. and gadolinium-enhanced MRI is a more sensitive and specific test for this condition. staying both still and awake. If feasible it offers excellent frequency specificity.9 These potentials are very small and rarely reach more than 1 mV (potentials of 10 mV may be obtained in electrocochleography). as such its presence can be associated with clinical hearing. This is particularly useful in children as it is non-invasive and not influenced by anaesthetic. It is too late to be considered a primary cortical response and almost certainly represents a secondary. Intraoperative testing. Unusual results may indicate multiple sclerosis. with active on the vertex. as movement and consciousness level can easily influence the response. but it is not frequency specific. Threshold testing. However.3 5. 4. 3.or triphasic wave commencing after 50 msec and continuing beyond 200 msec. Unfortunately. it is strongly influenced by the patient’s conscious level and attendance to the stimulus and so is only of value in the cooperative patient. In this case the I-V interval in the affected ear should be prolonged by more than 0.7 5. Tone bursts are the preferred test stimuli and are presented by headphones. Brainstem lesions. . The technique may be used as a monitor during tumour surgery designed to preserve hearing. Clinical indications 1. Fewer than 100 responses need be sampled to achieve a useful result. Cortical electrical response audiometry The cortical ERA (vertex or V potential) is a relatively late phenomenon and can be detected as a bi. perceptual cortical phenomenon.0 4. Surface electrodes are placed. 2. reference on either mastoid process and ground on the forehead. BERA can be used to define the site of a brainstem lesion depending on the presence or absence of successive waves.

Hyde ML. p. Radiology in ENT. p. 194. 257. p. Related topics of interest Acoustic neuroma. any more would be too timeconsuming. Handbook of Audiological Techniques. Non-organic hearing loss.2 and 3 kHz. 2. 167. 254. In medicolegal cases this is restricted to 1. London: Butterworth-Heinemann. Central deafness. p. In rare patients ECochG and BERA are normal but the V-potential is absent. p. Paediatric hearing assessment. 1994. Further reading Ballantyne D. . 192. Pure Tone Audiogram. Menière’s disease. 239. Threshold testing. Noise-induced hearing loss. p. 1990. Current Opinion in Otolaryngology and Head and Neck Surgery.EVOKED RESPONSE AUDIOMETRY 81 Clinical indications 1. Auditory evoked potentials. 1. p. 2: 177–185.

who sits opposite the ear to be examined and reflects light on to it. perichondritis and surgical scars. the pinna has to be drawn downwards and backwards. and that you are able to present your findings accurately and clearly. but avoid contact with the sensitive bony part of the canal.EXAMINATION OF THE EAR There is absolutely no doubt that you will be asked to assess an ear at some point during the course of any ENT examination. Common examination subjects include congenital lesions of the pinna. Ask which is the better hearing ear. Be particularly careful not to miss a fading postauricular or endaural scar. redness or tenderness. position the patient to one side of an electric lamp with the light source slightly above the level of the ear. When using a head mirror. outwards and back-wards. Introduce the otoscope speculum just past the hairs of the outer canal. The external auditory canal To examine the external auditory canal. . A good view of the tympanic membrane should then be possible. In infants. Note any discharge from the external auditory meatus as well as any inflammation of the skin. The examiner will want to establish that you have an orderly and thorough technique. The ear should be examined with either reflected light from a head mirror or an electric powered head light. You will be asked how you would manage the patient. The pinna Examine the pinna in front and behind for signs of inflammation or skin lesions. Time taken in practising your technique is therefore well spent. so be thinking about this as you present your examination findings. pull the pinna upwards. Select a suitably sized speculum for insertion into the external canal. owing to non-development of the bony external meatus. It is not just a question of spotting the particular clinical signs or disease process. The patient should be seated sideways to the surgeon. The mastoid process should be carefully examined for scars. Introduce yourself to the patient before starting the examination. Common examination subjects include canal stenosis and exostoses. cauliflower ears. Always begin the examination with the better ear and never touch the patient before asking if there is any tenderness.

2. Introduce yourself to the patient. Tuning fork tests. should then be performed to help differentiate between a conductive and sensorineural hearing loss. Other tests The postnasal space should be examined to exclude a lesion and if possible to obtain a view of the Eustachian tube orifice.EXAMINATION OF THE EAR 83 The tympanic membrane Look for the prominent lateral process and handle of the malleus. size and whether it is central or marginal. The long process of the incus is frequently observed behind and parallel to the handle of the malleus and it is sometimes possible to see it articulate with the head of the stapes. Look for conjugate deviation of the eyes away from the examined side and then (whilst maintaining pressure) nystagmus in the direction of the diseased side. 10. The Rinne and Weber tuning fork tests. A Siegle speculum or otoscope with a pneumatic attachment should be used to assess the mobility of the membrane. Facial nerve. Fistula test. Position the patient. 7. Summary of examination of the ear 1. The non-test ear is masked either by using a Bàràny noise box or by pressing the tragus backwards and rotating it with the index finger. Free field voice tests. round window. using a 512 kHz fork. In a short case examiners will sometimes stipulate that they are only interested in facial nerve function. If the patient has had mastoid surgery determine the type of cavity. 4. Use double figure numbers or bisyllable words as the words the patient is asked to repeat should not be easy to guess. a perforation or tympanosclerosis. 3. dehiscent Fallopian canal or some tympanosclerosis may be visible. Remember to tell the patient what you are doing beforehand. . assess access (meatoplasty size and height of the facial ridge) and decide if the cavity is healthy or not. 8. Pneumatic otoscopic examination of the tympanic membrane. The cranial nerves should be formally examined if there is active ear disease. If you do discover a perforation then make sure you can describe what you see looking through it. 5. The patient sits side on to the surgeon so that lip reading is not possible. 9. Immobility may be due to fluid in the middle ear. and this should always be routinely tested in examination of the ear. incudostapedial joint. 6. Postnasal space. Ascertain which is the better ear and start with this. Examine all quadrants of the membrane. for example the promontory. Inspect the pinna. Hearing tests Perform free field speech tests by asking the patient to repeat words spoken with a whispered voice. conversation voice and shouted voice at 60 cm from the ear. mastoid and external auditory meatus. Perform a fistula test by applying tragal pressure or preferably use the pneumatic otoscope. If there is a perforation note its position.

86. . p. 45. Examination of the throat.84 OTOLARYNGOLOGY Related topics of interest Clinical assessment of hearing. p. 84. p. Examination of the nose.

snoring and cosmetic deformity. If a lesion is immediately obvious. An old examination favourite is a patient with the lupus pernio rash of sarcoid on their nose. The thickness of the skin may be relevant if cosmetic surgery is contemplated. the width or projection of the tip. Assess the mucosa. relevant investigations and treatments of these conditions. A previous history of trauma or allergy may also be relevant. Lift the tip of the nose with the thumb to obtain a view of the nasal vestibules. Do not assume that they will be the only abnormality. It is therefore essential that you are familiar with the aetiology. abnormal sense of smell. signs can be elicited quickly and management of the common diseases makes good discussion.EXAMINATION OF THE NOSE The diagnosis in nasal disease is often obvious after an accurate history has been taken. bruising. Common findings are septal deviation. This is more elegant than sitting with your legs astride the patient’s. Nasal disease is common. septal perforation and nasal polyps. There may be a combination of signs (for example. erythema or for ulceration of the skin. a deviated septum and nasal polyps) so be thorough with your examination. Pay particular attention to its size and shape: the convexity or concavity of the dorsum. the deviation of the nose. Inspection of the external nose Examine the nose in relation to the rest of the patient’s face. The nasal cavity Anterior rhinoscopy is carried out using a Thudichum speculum. be thorough in the rest of your examination. with a septal perforation. The patency of the nasal airway is assessed by occluding each nostril in turn with the tip of the thumb and asking the patient to sniff or alternatively watching the shiny surface of a Lack tongue depressor held under the nose cloud over as the patient exhales. Be especially vigilant to look for a fading lateral rhinotomy scar or hidden bicoronal incision wound behind the hairline. Sit with your knees together and to the right side of the patient’s legs. headache and facial pains. Turn the patient’s head to the left and then to the right to check the profile. for example nasal polyps or a nasal tumour. Gently introduce this into the nose remembering that the nasal mucosa is very sensitive. Position of the patient Introduce yourself to the patient and sit opposite with an electric lamp at eye level over the patient’s left shoulder. note the position in relation to the turbinates and septum. Look for swelling. rhinorrhoea. hypertrophied turbinates. The essential symptoms are nasal obstruction. epistaxis. note its . postnasal drip. sneezing. the shape of the columella and nares.

Anterior rhinoscopy with a Thudichum speculum. 7. 3. Postnasal space examination. If a better view is needed the nasal mucosa can be shrunk using a local anaesthetic/vasoconstrictor (e. In clinical practice a 0–4-mm 0° or 30° nasendoscope can be used. Assess movement of the soft palate and if there is a bifid uvula be aware that this may signify a submucous cleft. 2. This is a difficult procedure and needs practice.86 OTOLARYNGOLOGY colour. The neck Inspect and palpate the neck and look for the presence of lymphadenopathy. Neck. Note any lesions or perforation of the septum. Introduce yourself. The fossae of Rosenmüller lie immediately above the tubal orifices and can be the site of a nasopharyngeal carcinoma. This will allow an inspection of the lateral nasal wall and the anatomy (and any pathology) of the middle meatus. 4. Oral examination Inspect and percuss the upper teeth. Inspect the posterior end of the septum.g. Examine the septum for its position in relation to the nasal airways. vascularity and crusting. Position the patient. 5. The nasopharynx Explain to the patient what you are about to do. through which the posterior ends of the inferior turbinates may be visible. Examine the lateral nasal wall and evaluate the size and colour of the inferior turbinate. Report the problem to the examiner and suggest that in normal circumstances you would proceed to use a flexible fibreoptic nasendoscopy after applying topical anaesthetic and decongestant to the nasal airway. the posterior choanae. In the lateral wall the tubal ridges of the pharyngeal ends of the Eustachian tubes can be seen. Oral examination. Inspect the external nose. Drainage from the posterior part is to the middle deep cervical nodes. 6. Summary of examination of the nose 1. The lymphatic drainage from the anterior part of the nose is to the submandibular nodes and upper deep cervical nodes. . 8. is it deviated to one side or is it dislocated off the maxillary crest? Examine the mucoperichondrium for its colour and vascularity. Some patients have too strong a gag reflex to allow adequate examination. The floor of the maxillary sinus lies over the alveolar process of the maxilla and the roots of the second premolar and first molar teeth. 5 or 10% cocaine hydrochloride or phenylephedrine with lignocaine). Warm a small postnasal mirror and pass it through the mouth while gently holding the tongue down with a tongue depressor. Examine the nasal tip and vestibule and assess the nasal airways.

p. 86. 174.EXAMINATION OF THE NOSE 87 Related topics of interest Examination of the ear. . 82. Nasal polyps. p. p. p. Examination of the throat. Nasopharyngeal tumours. 180.

Take two metal tongue depressors and insert them to retract the buccal mucosa on each side. • Examine the patient’s neck: inspect and palpate the neck. the patient should sit opposite the surgeon with an electric lamp positioned at eye level over the left shoulder. if in doubt it is better to be thorough. dysphagia. The two tongue depressors are then used so that the buccal mucosa. Remove any neck scarf which may hide a wound or stoma. Common findings are patients with vocal cord paralysis. or an electric head light can be used. There are a few scenarios: • Examine the patient’s throat: systematically examine the patient’s pharynx and larynx as you would any patient in clinic who complained of the aforementioned symptoms. The oral cavity Inspect the lips for perioral lesions. Check over the palate. teeth and alveolar ridges and the opening of the parotid ducts (opposite the upper second molar) can be examined. Expose the whole of the neck up to and including the clavicles. cough. lump in the throat. unfortunately applied indifferently by some examiners to the pharynx and larynx. This should allow an inspection of the dorsal and ventral surfaces of the tongue. Ask the patient to protrude the tongue and move it from side to side and then up to the palate and down. The technique outlined in this topic is ideal for a long case but may need to be modified for a short case. The surgeon should sit with knees together and legs to the right side of the patient’s. Position of the patient A head mirror to reflect light from a bulls eye lamp. the tongue’s lateral borders and the floor of the mouth. Throat is a vague term. referred otalgia. it also tests hypoglossal nerve function. • Examine the mouth: inspect and examine the oral cavity. vocal cord oedema. Then dispense with one of the tongue depressors and use the other to depress the tongue. vocal cord nodules. If a head mirror is used. Unless clearly stipulated. the tonsils and the posterior pharyngeal wall. Listen carefully to the examiner and do what is asked. Ask the patient to say ‘aah’ and check . laryngeal papillomas. occasionally patients with a neoplasm and laryngectomy patients. vocal cord polyps. sore throat. On the other hand. do not assume that the examiner merely wants an indirect laryngoscopy performed. Ask the patient if there is any tenderness in the mouth.EXAMINATION OF THE THROAT The symptoms associated with throat disease include hoarseness. However. do not irritate the examiner by examining parts of the patient that have not been mentioned. lump in the neck and weight loss. Ask edentulous patients to remove their dentures.

If the patient nose breathes and arches up the tongue. Note any abnormal move-ment or fixation of the cords. Ask the patient to protrude the tongue and gently grasp it with a swab held in the left hand. the usual site of origin of nasopharyngeal carcinoma. Inspect the base of the tongue. Ask the patient to swallow and watch the larynx move. The patient should then be requested to breathe normally through the mouth as the mirror is introduced gently up to the soft palate. If the patient is still unable to tolerate the procedure spray the nose with local anaesthetic and decongestant and use a flexible nasendoscope. In clinical practice the PNS can be examined by using a 2. In these cases it may be possible after spraying the oropharynx with lignocaine. Some patients still need to be assessed under a general anaesthetic. the ventricular folds and the vocal cords. obstructing the view. Warm a postnasal mirror and pass it through the mouth while gently holding the tongue down with a tongue depressor. Bimanually palpate the floor of the mouth overlying the submandibular duct for calculi or masses. the aryepiglottic folds. Be sure to tell the patient to avoid food and drink for the next hour because the gag reflex is impaired. The movements of the vocal cords are studied by asking the patient to say ‘ee’ followed by a deep breath and ‘ee’ again. The neck should be palpated from behind and in an orderly sequence so that no areas are missed. as a tumour in this site may not be visible but easily palpable. Get the patient to breathe deeply in and out through the mouth and note any stridor. Ask the patient to count to 10 and assess the voice. and then both sides of the epiglottis. it is possible to obtain some improvement by asking the patient to quietly make a’hah’ noise breathing in and out. Postnasal space examination Explain to the patient what you are about to do. the vallecula and the upper part of the epiglottis. Start at the mastoid bone and palpate down the line of the trapezius muscle and in the posterior triangle down to the clavicle. and to avoid burning the throat and aspiration. Warm a laryngeal mirror and check its temperature on the back of your hand. Be gentle. Feel for supraclavicular and infraclavicular nodes. Examine the posterior pharyngeal wall. the arytenoids. It is unlikely in an examination that the patient will have an overactive gag reflex as patients are specially selected. An enlarged neck mass may be visible: note its position and inform the examiner that you have seen it. Some patients are unable to cope with an indirect laryngoscopy because of an overactive gag reflex. Examination of the neck Check the neck for any obvious skin lesion or ulceration. above which lie the fossae of Rosenmüller. Palpate the base of tongue. Ask the patient to breath gently through the nose. Remove the tongue depressor and put a glove on. ulceration or exophytic lesion. but be particularly vigilant on inspection of the laterally placed Eustachian tube elevations. This is usually well tolerated and allows a more thorough inspection and assessment of vocal cord movement. After a few minutes the soft palate and uvula will be anaesthetized. the pyriform fossae. A thyroid goitre may also be seen moving with the larynx.7mm 30° rigid or flexible nasendoscope. Look for any obvious lesion. Check that the patient does not have a stoma. Note any inflammation.EXAMINATION OF THE THROAT 89 movement of the palate. Ask the patient if there is any tenderness. Be careful not to overlook a fading wound. . Indirect laryngoscopy Explain to the patient what you are about to do.

p. Summary of examination of the throat • • • • • • • Introduce yourself to the patient.90 OTOLARYNGOLOGY Then palpate down the line deep to the anterior border of the sternocleidomastoid muscle for deep cervical nodes. shape. Examination of the neck. If you think a lump is cystic see if it transilluminates. feeling the trachea. laryngeal cartilages and hyoid bone. p. Assess speech. Oropharyngeal carcinoma. p. If a lump is palpated in the anterior triangle see whether it moves on swallowing. 203. 84. If you think a lump is pulsatile or attached to the carotid. submandibular nodes. p. Oral cavity carcinoma. auscultate and listen for a bruit. . Indirect laryngoscopy. 82. size. Examination of the nose. When your fingers reach the suprasternal notch. 138. Feel for submental lymph nodes. 197. Laryngeal carcinoma. 180. Nasopharynx. Position the patient and expose the neck down to the clavicles. Oral examination (oral cavity and oropharynx). thyroid gland. Loss of normal laryngeal crepitus (Trotters sign) may indicate a postcricoid neoplasm. palpate up the anterior triangle. p. Related topics of interest Examination of the ear. the parotid gland. Nasopharyngeal tumours. preauricular nodes and finally occipital nodes. If a lump is felt note its site. consistency and fixation to adjacent tissues or skin. p.

Wet wax is produced by most people of African origin and caucasians and is familiar as moist. Impaction is commoner in males owing to the presence of thicker. granular and brittle. less sticky. the superficial keratinized squamous epithelium is constantly shed. Wax Wax can be secreted in one of two forms. Epithelial migration In all other parts of the body. coarser hairs in the lateral part of the external auditory meatus (EAM). The glands are found in the skin of the outer third of the external acoustic meatus and secrete a liquid material at the base of the hairs. keratosis obturans. Foreign bodies in the ear canal. zealous use of cotton buds and even a hearing aid mould may impede the normal flow of wax to the periphery. This natural process can be upset by a number of factors and cause wax impaction. otitis externa and conjenital abnormalities are discussed elsewhere in separate topics (see Related topics of interest). extostoses and osteomas. when it moves laterally. ear wax tends to become drier with age as a result of reduced glandular numbers and activity.EXTERNAL EAR CONDITIONS Ear wax This chapter confines itself to a discussion of ear wax. In some people no obvious cause is found to account for the impaction and it has been suggested that desquamation of the superficial layer of the meatal epidermis is impaired. Narrow canals. Squamous epithelium on the tympanic membrane moves radially until it reaches the canal walls. evaporation occurs to leave a sticky. The gene for wet wax is dominant. squames and microbes with relative ease. After secretion. waxy substance that is able to trap dirt. allowing its passage out of the external auditory meatus. usually as a result of friction from clothing or washing. sticky and honey-coloured. Regardless of type. This is not possible in the external ear canal and so it has developed the property of epithelial migration. It then mixes with the secretion of the ceruminous and pilosebaceous glands and any collected debris to form what we recognize as ear wax. . Wax is then normally loosened by transmission of movement from the temporomandibular joint from chewing or talking. When it reaches the hair-bearing cartilaginous portion of the canal the superficial layer starts to separate. The dry type is more common in Mongoloid ethnic groups and tends to be greyer in colour.

pain.92 OTOLARYNGOLOGY Clinical features Impaction of wax can cause a sensation of obstruction. Keratosis obturans This uncommon condition occurs when there is a failure of the normal process of migration. on the other hand. vertigo and coughing (via the auricular branch of the vagus—Arnolds nerve). In both conditions. Otalgia is usually the dominant feature. a known or suspected perforation and a difficult ear. deafness. They are hyperostoses of the tympanic bone of the external canal. The procedure is often best preceded by a week or two of ceruminolytic agent use (sodium bicarbonate drops are efficacious. they rarely . Osteoclast-stimulating mediators are produced. These direct a jet of warm (body temperature) water along the roof or posterior canal wall so that it passes behind the wax and forces it outwards. The keratin takes this appearance because the part in contact with the air oxidizes and changes colour. Exostoses and osteomas Osteomas are uncommon benign tumours of bone usually arising from the tympanosquamous or tympanomastoid suture line. The otoscopic appearances are similar to an acute otitis externa around impacted wax. Although relatively safe. In these cases removal under direct vision with an operating microscope using microsuction or waxhooks is a more appropriate and safer alternative. safe and inexpensive). Topical antibiotic/steroid combinations are advised to prevent a secondary otitis externa. otalgia. often caused by a narrow and/or tortuous external meatus. As with collections of keratin anywhere. otitis externa and rarely tympanic membrane perforation and otitis media. Contraindications to syringing include frequent previous episodes of otitis externa. are common. Most of these symptoms are improved by removing the wax. this sets up a low-grade inflammatory response. This is often difficult as the patient is usually in considerable pain and a general anaesthetic is not infrequently required. resulting in a resorption of bone and usually a widening of the bony canal. which can usually be accomplished easily by syringing. although the lumen of the canal may be reduced. Management Syringing involves the use of an old fashioned Higginson or a modern electric-pump syringe. In the long term these patients require periodic monitoring and aural toilet. local trauma. Management Removal of the keratin plug is essential to control the inflammatory process. They appear to be caused by a periosteal reaction to exposure to cold. usually from swimming. Clinical features Patients usually present with an acute exacerbation of the inflammatory process. although wax impaction is a relatively rare cause of hearing loss. although there is inevitably a conductive hearing loss from the occluded canal. Exostoses. Keratinocytes and keratin debris collect in the deep part of the external auditory meatus. complications may occur and include coughing.

Otolaryngology— Head and Neck Surgery. Related topics of interest Examination of the ear. If problems do occur they are usually related to impairment of the normal process of epithelial migration. 85:346–349. Sheehy JL. Mulley GP. Osteomas can often be removed via the external canal. 103. Further reading Hanger HC. p. 82. 90:337–342. 1982. while exostoses will more often require a formal postaural or endaural approach. p. Diffuse exostoses and osteomata of the external auditory canal: a report of 100 operations. Otitis externa. In these cases surgical removal may be indicated. 209. 1992. Foreign bodies. Cerumen: its fascination and clinical importance: a review. .EXTERNAL EAR CONDITIONS 93 result in symptoms. p. Journal of the Royal Society of Medicine.

Hemifacial spasm. The voluntary and reflex movement of groups of muscles that normally do not contract together. with the otic ganglion and sympathetic afferents from geniculate ganglion branches and with the auricular branch of the vagus nerve from a branch of the mastoid segment of the facial nerve. It is thought to be most commonly caused by compression of the nerve by an artery in the posterior fossa. In this condition there are multiple fine but asynchronous facial movements. throat and neck pain which may occur with malignant disease. Evoked electromyography and maximal stimulation test response neurophysiological studies show that a neuropraxia injury gives normal results and an axonotmesis up to 10% of normal. greater auricular and the auriculotemporal nerves and multiple communications with branches of the trigeminal nerve. face and neck pain associated with herpes zoster and Bell’s palsy. . ear. it is important to appreciate that there are supranuclear or upper motor neurone (motor cortex to pontine facial nuclei) and infranuclear or lower motor neurone causes of a facial nerve palsy. but more severe injury gives no response. 1. Injection of botulinum A toxin into the orbicularis oculi may provide temporary relief. partial transection and complete transection. Synkinesis. Cerebellopontine angle tumours may also cause this phenomenon. These studies can be used to provide a prognosis and to indicate if recovery is occurring. It is associated with brain stem gliomas and multiple sclerosis. vagus. Facial myokymia. Extracranially there are communications with the glossopharyngeal. mastoid and extracranial portions. axonotmesis. This may occur after neurotmesis (or more severe injury) when the axons do not find their correct endoneural sheath. This is unilateral or more commonly bilateral involuntary spasmodic eye closure. occipital. Blepharospasm. Lacrimation with eating can occur as a result of facial nerve injury in the region of the geniculate ganglion. This is an intermittent spasm of the orbicularis occuli muscle which may spread to include other or all muscles of facial expression. meatal. where motor axons find the myelin sheath within the greater petrosal nerve. face. For example blinking. tympanic. If this is confirmed by an MRI scan and angiography the cause may be treated surgically. 3.FACIAL NERVE PALSY Although the detailed anatomy of the facial nerve will not be discussed. 2. Injury may be classified into a neuropraxia. Associated features Altered facial nerve function occurs with a variety of conditions and in a variety of forms. and the referred otalgia. The infranuclear portion can be divided into cerebellopontine angle. 4. These interconnections explain the mastoid. labyrinthine. may be accompanied by movement of the corner of the mouth. 5. Communication with the vestibulocochlear nerve occurs within the internal auditory meatus. neurotmesis. Crocodile tears.

but not severe synkinesis. normal symmetry and tone Motion Forehead: moderate-to-good function Eye: complete closure with effort Mouth: slightly weak with maximum effort Gross Obvious. Brackman DE. with permission from Mosby Inc. Otolaryngology and Head and Neck Surgery 1985. At rest. asymmetry Motion Forehead: none Eye: incomplete closure Mouth: slight movement No movement at all III—Moderate dysfunction IV—Moderately severe dysfunction V—Severe dysfunction VI—Total paralysis . normal symmetry and tone Motion Forehead: slight-to-moderate movement Eye: complete closure with effort Mouth: slightly weak with maximum effort Gross Obvious weakness and/or disfiguring asymmetry At rest. normal symmetry and tone Motion Forehead: none Eye: incomplete closure Mouth: asymmetric with maximum effort Gross Only barely perceptible motion At rest.). to grade 6: total paralysis. resting tone and muscular movement at forehead. Grade I—Normal II-Mild dysfunction Characteristics Normal facial function in all areas Gross Slight weakness noticeable on close inspection May have slight synkinesis. but not disfiguring difference between the two sides Noticeable. contracture or hemi facial spasm At rest. eye and mouth are used to score the dysfunction. Factors such as symmetry.FACIAL NERVE PALSY 95 Severity grading The most commonly used system is that of House and Brackmann which grades from 1: normal function in all areas. 93:146–147. All ENT medical staff should grade all new facial palsy patients and follow-ups according to the HouseBrackmann grading system (reproduced from House JW.

but only 60% recover to House and Brackmann grade 1 or 2. and many surgeons will therefore advocate surgical decompression of the nerve in these circumstances. Reassurance and explanation are essential for all patients. 5. It recurs in 12%. The communications of the facial nerve may allow the face. External trauma includes head injuries or penetrating trauma. a sensorineural hearing loss. General. Facial nerve palsies caused by tumours and infection are discussed elsewhere (see Related topics of interest). Other causes. For example secondary to multiple sclerosis. Infection (4%). 4. It is probably a virally induced immune response that leads to inflammation. For example sarcoid. swelling and consequent impaired function of the facial nerve. An evoked electromyogram (EEMG). 2. Tumour (6%). In patients with marked symptoms a lateral tarsorrhaphy or the insertion of a gold . Caused by herpes zoster virus. drugs.96 OTOLARYNGOLOGY Causes 1. more commonly on the contralateral side. Ramsay Hunt syndrome (synonym: herpes zoster oticus) (7%). eye closure with tape on to which is applied a light pressure dressing of cotton wool. This may be external or iatrogenic. altered facial sensation and taste. A lower motor neurone facial palsy may occur with acute suppurative otitis media (in the 8% who have a dehiscent Fallopian canal). The prognosis overall for those below this level is only a 20% chance of achieving grade 1 or 2 recovery. ointment at night and eye protection when outdoors on windy or hot dry days with an eye pad. These may arise from the nerve (facial nerve Schwannoma). chronic suppurative otitis media either with or without cholesteatoma and malignant otitis externa. it is important to know the severity of a palsy as soon as possible after nerve injury as this will influence the management. If the EEMG response remains above 10% of normal during the first 10 days after injury there is an excellent chance of grade 1 or 2 recovery (85%). 6. Central causes. An acute lower motor neurone facial palsy of unknown aetiology and therefore a diagnosis of exclusion. myasthenia gravis and Guillain-Barré syndrome. gliomas or cerebrovascular accidents. sometimes necessary in suspected Bell’s palsy as this is a diagnosis of exclusion. palate and buccal mucosa to become involved. tinnitus and vertigo are all common in Ramsay Hunt syndrome. neck tongue. Severe otalgia with vesicles involving the external ear associated with crusting. Bell’s palsy (55%). Clinical features In Bell’s palsy the facial nerve palsy is usually of rapid onset and associated with otalgia. Eye care is mandatory in order to prevent corneal ulceration and comprises artificial tears. Trauma (19%). Management 1. external compression of the nerve (vestibular nerve schwannoma). Investigations A high-resolution CT or MRI scan to include the petrous temporal bone will exclude cerebellopontine angle tumours as a source of the palsy. external ear canal oedema. is helpful. or invasion of the nerve (most commonly with parotid tumours). It may localize injury in cases due to trauma or chronic suppurative otitis media. When trauma has caused the palsy. 7. 3. in which a stimulating electrode is placed adjacent to the stylomastoid foramen and recording electrodes are placed either on the skin over the facial muscles or through the skin into the muscles. usually in the parotid region. It rarely recurs.

Fisch advocates early decompression of the meatal portion of the facial nerve by a middle fossa approach. In summary. and immediate exploration is indicated. This must be performed without tension on the nerve. although formal decompression of the nerve is probably unnecessary. Brackman DE. The facial nerve is usually sacrificed if it has been infiltrated by tumour which cannot therefore be teased off the nerve. and should this not be possible after preparation of the stumps. If a complete lower motor neurone facial palsy is noted immediately after external trauma. this suggests that the nerve has been severed. e. A partial palsy or a delayed onset of a palsy can be managed conservatively with sequential EEMG monitoring. perhaps because significant debridement was necessary or the injury involved a significant length of nerve. Some groups also advocate the use of acyclovir as viral antigens have been found. . El-Kashlan H and Kileny P. temporalis muscle sling or a gold weight for the upper eyelid. The management in these circumstances is discussed elsewhere (see Related topics of interest). and splinting the external ear canal with a pope wick expanded with antibiotic/steroid drops will reduce the otalgia. 93: 146–147.FACIAL NERVE PALSY 97 weight into the upper eyelid may be necessary as a permanent or temporary manoeuvre to ensure adequate eye closure. (d) Tumour. (c) Trauma.g. (b) Ramsay Hunt syndrome. (a) Bell’s palsy. A cable graft is indicated in these circumstances. as this is the portion most often implicated as being affected in Bell’s palsy. Although no placebo-controlled double-blind trial has been reported. It is preferable to anastomose the proximal to the distal stump after each has been prepared to present a clean surface. Adequate counselling regarding eye care is essential. Facial nerve grading system. 4: 369–374. may be indicated. Follow-up and aftercare If no recovery of function has occurred within a year of injury in those with a severe or complete palsy (grade 5 or 6). Facial reanimation. then a cable of sural or great auricular nerve is necessary. Specific. Otolaryngology and Head and Neck Surgery. 1998. 1994. a permanent facial reanimation procedure. Current Opinion in Otolaryngology and Head and Neck Surgery. many practitioners advocate a short course of steroids provided there are no contraindications in the patient’s medical history. Maximum recovery may take 12 months so that no decision regarding permanent facial reanimation procedures should be undertaken until then. House JW. 2. a palsy secondary to ASOM should be treated conservatively but that secondary to CSOM requires mastoid exploration to eradicate the underlying disease. 1985. Adequate analgesia is essential. (e) Infection. Current Opinion in Otolaryngology and Head and Neck Surgery. Outpatient facial nerve evoked electromyography testing. Further reading Bradford CR. The commencement of acyclovir 800 mg five times daily for 7 days as early as possible during an attack may reduce the length of the infection and postherpetic neuralgia. 6:334–337.

98 OTOLARYNGOLOGY Related topics of interest Acute suppurative otitis media. p.63. 5. 38. Chronic suppurative otitis media. p. p. . Cosmetic surgery.

ears. A number of pain assessment tools have been developed which may aid the clinician in accurately defining the pain. sinuses. The McGill Pain Questionnaire attempts to define the qualitative aspects of pain. agonizing. stabbing which are of more value in suggesting diagnosis than words that indicate intensity e.g.FACIAL PAIN AND HEADACHE A. • Cranial neuralgias. eyes. tribute is paid to this fact by the plethora of treatment options. . He should be encouraged to use descriptive terms. neck. Miscellaneous headaches unassociated with structural lesion. nerve trunk pain and deafferentation pain. • • • • • Migraine. particularly if symptoms have been present for some time. Tension-type headache. It is inevitable that the sufferer will have a significant emotional component to the pain. The International Headache Society has provided a detailed classification of headache. teeth. and successful pain management will not be achieved without acknowledgement of this fact. such as burning. It is unsurprising that pain arising from there is often misunderstood. throbbing. nose. sore. excruciating. cramping. The reader is reminded of the definition of pain issued in 1986 by the International Association for the Study of Pain which reads as follows: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or expressed in terms of such damage. Headache or facial pain associated with disorder of cranium. the patient will frequently find it difficult to convey the experience of pain to the listener. Up to 50% of cases of facial pain never receive a definitive diagnosis. misdiagnosed and mistreated. If facial pain is to be successfully managed it is essential to spend sufficient time with the patient to elicit a full history. mouth or other cranial or facial structures (referred pain). Classification ication of headache Headache is a common presenting complaint. while the Visual Analogue Scale is the most widely-used pain intensity measure. When taking a pain history. Cluster headache and chronic paroxysmal hemicrania.Leach The head and neck is an anatomically and neurologically complex region. Some of the more common diagnoses and their management are discussed briefly.

A careful history will reveal clear differences from TGN by duration of attacks. Experimental studies in animals suggest that the trigemino-vascular system is the final common pathway where the migraine headache is generated. which is effective at any stage of an attack when given by subcutaneous injection. Only about 10% of migraine headaches exhibit the classical signs of aura (most commonly a visual phenomenon. It is beyond the scope of this chapter to list them all. Prophylaxis consists largely in avoiding precipitating factors. It takes its title from the grouping together of attacks into clusters. A rise in cerebral blood flow in the occipitoparietal cortex precedes the headache. It is more common in women and there is often a family history. Cluster headache This is a rare but important cause of unilateral facial pain. Drugs such as ( -blockers. Age of onset is between 20 and 40 years and there is a male-female ratio of 7:1. The aetiology is not fully understood. Diagnosis is sometimes confused with trigeminal neuralgia. there are seventeen subgroups within the ‘migraine’ section). which is usually unilateral in onset. The headache itself is probably due to the dilatation of cranial non-cerebral vessels. Onset of symptoms is usually between puberty and the fifth decade. but may take the form of dysaesthesia in the ipsilateral limb or face and as a mood change) which precedes the headache by 10–60 minutes. An impending attack may be aborted with an ergotamine preparation taken orally or by inhaler. diltiazem. a cranioselective 5-HT1 agonist. consisting of 1–8 headaches per day for 3–12 weeks. Symptom-free periods of 3–18 months separate the clusters. although there is undoubtedly a vascular component. methysergide and cyproheptadine have all been used in an attempt to stabilize the cranial circulation. Precipitating factors include psychological stress.and phonophobia and nausea. It lasts for 4–72 hours and the sufferer is free of pain between attacks. endocrine changes (such as menstruation) and dietary intake (especially tyramine-containing foods and irregular meals). non-classifiable.100 OTOLARYNGOLOGY • Headache associated with: • • • • • • head trauma vascular disorders nonvascular intracranial disorder substances or their withdrawal noncephalic infection metabolic disorders • Headache. Also available is sumatriptan. but which may spread to involve the whole head and face and is accompanied by photo. associated symptoms and temporal profile. The characteristic feature of migraine is its throbbing nature. Migraine The prevalence of migraine headache in the general population is said to be 10–15%. The full classification has many subgroups within each diagnostic category (for example. pizotifen. and this is followed by a 25% reduction in flow spreading forwards from the occipital region. These changes seem to account for the symptoms of aura. The pain is deep and throbbing . Treatment consists of symptomatic relief with analgesics and anti-emetics.

methysergide (long-term use may cause retroperitoneal fibrosis) and calcium channel blockers have all met with some success. including sternomastoid. Treatment consists of physical therapy to the painful muscles and a dental splint which is usually worn at night to reposition the mandible and prevent bruxism (teeth grinding). Lack of a diagnosis rapidly results in frustration for the physician and loss of confidence in his or her abilities by the patient. Certain muscles appear to be particularly prone to developing trigger points. it is overlooked surprisingly often as a source of chronic pain. or sphenopalatine ganglion block with intranasal local anaesthetic. local anaesthetic injection or acupuncture needling of trigger points. either as a single event or a repeated microtrauma. Each attack lasts for 15 minutes to 3 hours. aching. There are always associated autonomic phenomena such as nasal congestion. temporalis. Treatment consists essentially in restoring normal function to the affected muscles by gentle stretching and mobilization. Pain is often referred forward from the occipital region to the temple.or bilateral. which refer either locally or to a distant site which is usually unrelated dermatomally or myotomally. eliciting TMJ tenderness and clicking. orbit or ear. This is described as a deep. ice. Symptom relief during an attack may be achieved with oxygen. Diagnosis is confirmed by observing restricted mouth-opening (less than 40mm inter-incisal). Myofascial pain usually appears on the affected side. . in particular the medial and lateral pterygoid muscles. A sensation of fullness or congestion in the ear may be mentioned. although it may in time become bilateral as a result of a general chronic tensing of head and neck muscles and assumption of a protective posture. trapeziums and neck strap muscles. If the pain has remained undiagnosed for some time it is common for a degree of pain behaviour to have developed. TMJ problems manifest themselves as clicking or popping in the joint. and of gradual or sudden onset. forehead. pain on chewing or mouth opening and locking if the internal derangement is severe. dull. To permit this it is helpful to reduce discomfort in the muscle body with cooling spray. The assistance of physiotherapists may be useful. There are no neurological abnormalities. Tension headache (also called myofascial headache) Considering that muscle accounts for about 30% of body weight. will either reproduce the patient’s pain or refer it to a characteristic reference zone. For prophylaxis such drugs as prednisolone in a reducing dose. pressure-like pain which may be uni. pterygoids. injected conjunctivae and facial sweating. Trigger points are palpable as tender bands within the muscle which. Sumatriptan given by subcutaneous injection may relieve an attack. such as poor posture or teeth grinding. when pressed. which causes transient cerebral vasoconstriction. Chronic tension headache does not respond well to analgesics and the most effective medication may be amitriptyline. Myofascial pain is usually associated with trigger points in the muscle and its surrounding fascia. It may appear at the same time each day during a cluster and may wake the subject from sleep. an associated myofascial syndrome commonly develops. In this situation psychological therapy may be required. Tension headaches and migraine may be related and may co-exist. Trigger points are thought to arise following muscle trauma.FACIAL PAIN AND HEADACHE 101 and is extremely severe. coupled with such techniques as deep relaxation and counselling to improve the patient’s insight into the condition. There will usually be trigger points in associated muscle groups. ergotamine subcutaneously or by inhaler. Temperomandibular joint (TMJ) dysfunction unction When anatomical disturbance of the TMJ occurs.

As with TGN. Pain commonly returns 6 months to 5 years after this. 2. although it has been described outside these age limits. It is believed to be caused by local demyelination of the trigeminal root entry zone. If a vascular loop has been demonstrated by MRI. dysaesthesia and paraesthesia along the course of the affected nerve. destructive lesions to the Gasserian ganglion with alcohol or glycerol injection. decompression of the nerve root via posterior fossa craniotomy has a high chance of prolonged symptom relief. most usually due to compression by a small. These form scabs . Triggers include talking. Side-effects may be problematic. it was associated with a high incidence of suicide. 3. causing an antidromic infection along the nerve. Diagnosis must demonstrate three elements: 1. Acute herpes zoster Most individuals acquire varicella zoster virus during childhood infection with chicken pox. The pain can induce spasms of the facial muscles on the affected side (hence tic). base of tongue. It has been suggested that GPN may be associated with an unusually long styloid process irritating the nerve. surgery of this nature carries significant morbidity. before effective remedies were widely available. other cranial nerves may give rise to neuralgia whose manifestation is identical to TGN. It affects men and women equally. Infection is commoner in the elderly and the immunocompromised. pain. also called tic douloureux. although other anticonvulsants such as clonazepam and phenytoin have been used. Glossopharyngeal neuralgia (GPN) is characterized by stabs of pain in the ear. lasting for seconds or minutes. acoustic neuroma. It presents with itching. Pain occurs within one or more divisions of the trigeminal nerve. followed a few days later by cutaneous vesicular eruptions. Gabapentin (100– 300 mg tds) has had promising results in treating neuropathic pain and has been awarded a product licence for this indication. especially in the elderly patient. followed by the maxillary (II) and ophthalmic (I) divisions. How-ever. as malnutrition due to inability to swallow is a distinct possibility. swallowing and coughing. TGN. Treatment should start with an anticonvulsant. It appears that the virus may lie dormant in the dorsal root ganglia of peripheral nerves for many years until opportunistically reactivating. Alternatively. is an agonizingly painful condition which usually affects 50–70-year-olds. Bilateral symptoms are rare. or radio-frequencey diathermy are usually effective. Carbamazepine (100–400 mg tds) is the most widely used drug. Neuralgia of the nervus intermedius is felt deeply in the ear. In the first half of the last (20th) century. and may also help to exclude other causes of these symptoms such as multiple sclerosis. base of skull tumours and vascular anomalies such as aneurysms and vertebrobasilar atherosclerosis. Although rarer. especially in the elderly. necessitating a repeat. tortuous artery or vein in the posterior cranial fossa. Pain is described as a brief intense electric shock or knife-like sensation. Adequate pain relief is important. with a trigger zone in the posterior wall of the auditory canal. Pain is elicited by normally-innocuous stimulation of a trigger zone. tonsillar fossa or beneath the angle of the mandible. The mandibular (III) division is the most commonly affected. and less invasive treatments are the rule. an aberrant vascular loop may be demonstrated near the nerve’s origin.102 OTOLARYNGOLOGY Trigeminal neuralgia (TGN) The principal sensory nerve to the head is the trigeminal nerve. MRI of sufficiently high resolution may demonstrate such a vessel. although patients must be warned that symptom relief will be accompanied by sensory loss to the affected part of the face.

and two studies indicate that women are affected more than men in a ratio of 3:2. which acts by depleting substance P levels (an important neurotransmitter in pain fibres). Also available is a topical preparation of capsaicin. Analgesics and acyclovir should be given systemically. uncontrolled studies have suggested that aggressive early therapy reduces the incidence of postherpetic neuralgia. extracted from chilli peppers. p. Treatment of burning pain and dysaesthesia is best achieved with tricyclic antidepressants such as amitriptyline in the lowest effective dose. and as an attempt to diminish the development of post-herpetic neuralgia (vide infra). It is thought that this phenomenon is caused by alteration of the modulating effect of large-diameter sensory nerves (proprioception) at the dorsal root entry zone (i. Sinusitis. both as an analgesic for the acute condition. Postherpetic neuralgia (PHN) Diagnosis of PHN is rarely difficult. but treatment often defies the efforts of the most determined physician. 108. which may account for the increased incidence of PHN with advancing years. . although attempts to confirm this finding have been inconclusive. Anticonvulsants such as carbamazepine. The incidence is reported as being up to 50% following acute infection. p.FACIAL PAIN AND HEADACHE 103 within a week or so and heal within a month. since the incidence of dose-related side-effects is high in the elderly. The mechanism of action of these drugs is unknown. It is most effective in treating burning pain. Constitutional upset frequently accompanies acute zoster and it may take weeks or even months for an elderly patient to recover fully. Early treatment with tricyclic antidepressants has been recommended. but occasionally throbbing or stabbing. the ophthalmic division of the trigeminal nerve and the fourth to tenth thoracic nerves are more commonly affected than others. Summary This is by no means a complete guide to diagnosis and treatment of facial pain. Related topics of interest Functional endoscopic sinus surgery. Treatment of acute zoster consists of pain relief and in speeding resolution of skin lesions. although they undoubtedly influence neurotransmitter systems high in the CNS. and examination must always include full assessment of cranial nerve function. The ability of nerve fibres to repair themselves diminishes with age. There is commonly an accompanying sensory deficit and allodynia (pain caused by a normally innocuous stimulus) to light touch is often a feature. A recent history of herpes zoster infection is followed by the development of pain in the affected area. gabapentin and valproate may help lancinating pain. Pain in ophthalmic zoster is relieved by stellate ganglion block with local anaesthetic. and techniques such as transcutaneous electrical nerve stimulation (TENS) and acupuncture may also be of value. 285. the pain gate is held wide open) following viral damage during the acute infection. It is more likely to develop in elderly patients. though this may take longer in the immunocompromised patient. Care-ful consideration must be given to the history and symptomatology. although such relief is limited to its duration of action.e. For reasons which are not understood. The pain experienced is usually burning. A number of small.

They may be inorganic or organic.to 3-year-old children. Inorganic foreign bodies include buttons. Treatment Removal is best accomplished with a wax hook or an old Eustachian tube catheter. plastic from toys. The child sits on either a parent’s or nurse’s knee. which will require removal under general anaesthetic. and stones. Have good illumination and all the instruments possibly required to hand. A unilateral nasal discharge is nearly always due to a foreign body. These are irritant and the nasal mucosa usually becomes involved in an inflammatory reaction causing a nasal discharge. It is possible in many children to remove the foreign body without the need for general anaesthesia. Management Confirmation of the presence of the foreign body is from the history and examination of the child. It is passed point downwards above the foreign body. In every case the nasal cavity must be examined afterwards as there may be a second foreign body more posteriorly. They are often asymptomatic and may be discovered only accidentally during an examination for an unrelated complaint. Inflammation and infection of the paranasal sinuses may complicate the problem. metal. Organic foreign bodies include sponge. Examination of the anterior nares is often possible with a head mirror or electric head lamp. rubber. The first effort will be the best and often the only attempt the child will allow. or soft organic objects such as sponge. If this fails or if the foreign body is situated posteriorly in the nasal cavity then a general anaesthetic will be required. The child should be discharged with a supply of Naseptin nasal barrier cream and oral antibiotics if there is any obvious infection. peas. beads. If nothing is visible then an auriscope may give a better view. Cupped forceps are preferable for the removal of thin objects. . This is initially mucoid. wood. but will eventually become mucopurulent and finally odiferous mucopus. which may be blood stained. reflecting light on to the elevated tip of the nose. paper. Occasionally deposits of calcium and magnesium carbonates and phosphates takes place around a foreign body to form a rhinolith.FOREIGN BODIES Foreign bodies in the nose Nasal foreign bodies are most commonly found in 2. The child must be cooperative and the surgeon gently reassuring. such as buttons. which is brought to the floor of the nose and raked anteriorly. and nuts.

will be able to localize the side and site with reasonable accuracy. Small fish bones are the commonest and usually lodge in the tonsil. then examination with a nasendoscope is useful. Large objects lying superficial to the external ear canal isthmus should not be syringed as there is a danger of wedging them in that area. as they will tend to push them further down the ear canal. vallecula or pyriform fossae. Suction or a fine hook may be used. It is rarely necessary to extract a foreign body through the posterior canal wall after a postaural incision. but usually requires the skills and facilities of a specialist. with the object viewed with an operating microscope. peas and beans) or inorganic (beads. If there is an otitis externa a swab should be taken. This is useful if permeatal extraction is not possible because of swelling of the canal walls from irritation. Objects of vegetable origin. Removal may appear to be easy. but organic objects may give rise to otitis externa by local irritation of the epithelium of the meatal walls. so must be killed or anaesthetized with chloroform water prior to syringing.FOREIGN BODIES 105 Foreign bodies in the ear Foreign bodies are inserted into the ears more commonly by school children than by toddlers. beans and nuts. the tympanic membrane should be examined to ensure it has not been damaged. Maggots grip on the external ear-canal skin. such as peas. Forceps are useful for soft material such as paper. and it is not unusual to find this in adult patients who have been attempting to clean their ears. The objects found can be organic (pieces of paper. If the patient can-not tolerate indirect laryngoscopy and a foreign body is suspected in the vallecula or base of tongue. 111-directed attempts at their removal by the untrained may lead to complications. Management A foreign body in the external ear canal is usually easily seen on otoscopy. seeds. buttons. the ear should be cleaned. Forceps should never be used to remove smooth spherical objects such as beads. crayons and stones). Treatment As a general rule. cotton wool or sponge. usually an adult. In some patients there will be no abnormal findings and a lateral soft-tissue radiograph is indicated. and antibiotic-steroid ear drops should be instilled. Foreign bodies in the pharynx Sharp and irregular foreign bodies may become impacted in the tonsils. One of the commonest causes of this is cotton wool. or if a large object has lodged at the isthmus. It is sometimes possible to remove the foreign body in the clinic. Once the object is out. Insects should be killed before syringing by instilling spirit drops into the ear canal. a tongue depressor and laryngeal mirror should reveal the offending bone. are hygroscopic and should not be syringed. most foreign bodies can be removed by syringing. A thorough examination with light reflected from a head mirror. If this too is normal they should be . to remove material of vegetable origin and large objects which lie superficial to the isthmus. but a general anaesthetic may be required for children and sensitive adults. base of tongue. Management The patient. rubber. pencil. Inorganic foreign bodies are often asymptomatic.

Widening of the postcricoid space or a persistent air bubble in the oesophagus may occur. In a patient anaesthetized with lignocaine spray and positioned on a flat bed with the neck and shoulders supported on a pillow it is sometimes possible to pass the blade of a McGill laryngoscope to depress the tongue. Barium swallow as an investigation is condemned because it makes . Treatment After the foreign body has been visualized. Patients who have been anaesthetized with lignocaine spray should be warned not to eat or drink for 2 hours as the pharynx will be relatively insensitive. This has its own light source and may help locate a foreign body in the pharynx. There may be localized tenderness in the neck and crepitus owing to surgical emphysema if there has been an oesophageal perforation. The commonest objects are coins in children and fish or meat bones in adults. General anaesthesia is required to remove a foreign body from the pharynx if the patient is young or unable to tolerate the above manoeuvres.106 OTOLARYNGOLOGY reassured and reviewed 2 days later. the pharynx should be anaesthetized with lignocaine spray. It is then often possible to grasp the foreign body with forceps and remove it swiftly and painlessly. The surgeon’s free hand can then be used to remove the object with forceps. Some foreign bodies are easily identified because they are radio-opaque. but may also occur at the level where the oesophagus is crossed by the left main bronchus or at the cardia. Clinical examination may be normal. By this time the sensation will usually have passed. Clinical features Adults are usually aware of having swallowed something and can localize fairly accurately the level at which it is impacted. The presence of an abnormality in the patient’s aerodigestive tract. The inexperienced may confuse calcification in the laryngeal cartilages with an opaque foreign body. Dysphagia may be total. Children and psychiatric patients may not be so reliable. Impaction is commonest at the level of the cricopharyngeus muscle. If the foreign body has caused a tear. A large bolus of food swallowed hurriedly may become impacted even in a normal oesophagus. Some fibreoptic nasendoscopes have a side arm which facilitate forceps and can be used to remove foreign bodies. Mentally handicapped and some psychiatric patients are at particular risk. The foreign body may cause coughing and excessive salivation. but if there are persistent symptoms the patient should be re-examined. Foreign bodies in the oesophagus Impaction of a foreign body depends chiefly on the size and shape of the object. surgical emphysema will be shown radiologically. for example a stricture. will make impaction more likely. Discomfort or pain in the oesophagus and difficulty in swallowing are the cardinal symptoms. but pooling in the pyriform fossae on indirect laryngoscopy is sometimes evident. Investigations Lateral and anteroposterior soft-tissue radiographs of the neck and chest radio-graphs are mandatory.

obstructive emphysema. vegetables. pips. Vegetable foreign bodies are particularly dangerous (nuts. If there is a mucosal injury the patient should have antibiotic cover. A foreign body may partly occlude the bronchus and act like a valve so that the partly obstructed lung becomes overinflated. Any unexplained choking fit on the part of the child should be treated with suspicion. the safest treatment is to admit the patient and give a dose of intravenous hyoscine butylbromide and diazepam. however. fruits) as they will cause an intense inflammatory reaction of the bronchial mucosa leading to a pneumonitis. Using a rigid oesophagoscope the foreign body is identified and if possible drawn into the end of the scope using forceps. if there is a good history suggestive of inhalation of an object. especially if any small object with which the child happened to be playing cannot be found. The scope and the foreign body should be withdrawn in unison under direct vision. Surgical repair should be considered depending on its site and extent. There may. Clinical features After the initial inhalation. . Adults usually give a clear history of foreign body inhalation. A foreign body which is causing a complete obstruction of a bronchus will produce a collapse of that lung segment. For this reason. If there is sharp or bony object. This will usually allow the oesophagus to relax and permit the passage of the bolus. The patient should have a barium swallow 2 weeks later to exclude an oesophageal neoplasm. followed by consolidation. The patient should remain in hospital for 24 hours postoperatively and receive nil by mouth for the first 4 hours and only water for the next 4 hours. be a cough with inspiratory and expiratory stridor. the child should have a bronchoscopy. The event can easily escape a parent’s notice. though Omnopaque 500 contrast medium can be used because it is clear. Radiolucent objects are suspected when there is unexplained atelectasis. Most inhaled foreign bodies enter the right main bronchus.FOREIGN BODIES 107 subsequent oesophagoscopy and identification of a foreign body more difficult. The neck should be examined to exclude surgical emphysema on the day of discharge. mediastinal shift or consolidation of the lung. or a wheeze. which causes choking and coughing. the patient requires an oesophagoscopy as soon as possible. and sometimes cyanosis. Foreign bodies in the trachea and bronchi Inhalation of a foreign object is most common in children under the age of 3 years. Some surgeons have suggested that the ingestion of cola fizzy drinks will encourage this process. Opaque objects are easily identified. Investigations Lateral and anteroposterior chest radiographs are mandatory. Treatment If the obstruction is due to an impacted food bolus. Perforation of the oesophagus should be treated with intravenous antibiotics and nasogastric feeding. which is larger and more vertical than the left. the foreign body may pass symptomless into the trachea.

. A variety of bronchoscopes. Related topics of interest Paediatric airway problems. A tracheostomy may be needed if there is oedema or obstruction of the larynx. either prior to or after bronchoscopy. Garret CG. Flexible fibreoptic bronchoscopes are used in some centres.108 OTOLARYNGOLOGY Treatment Bronchoscopy should be performed as soon as possible. 232. Current Opinion in Otolaryngology and Head and Neck Surgery. Removal via a thoracotomy is sometimes necessary if the foreign body cannot be retrieved by endoscopic methods. p. Further reading Spector BC. p. 6:416–420. Storz or similar instruments with Hopkins rod telescopes should be available with young children. 237. Antibiotics and physiotherapy may be necessary if there is any sign of pneumonitis. Paediatric endoscopy. Endoscopy and removal of foreign bodies. 1998. A senior ENT surgeon and anaesthetist are required. suction tubes and forceps appropriate to the nature of the foreign body and size of the patient need to be readily available.

Common locations for contact areas in the sinuses include the frontal recess and ethmoidal infundibulum. which aims to provide ventilation and drainage of the ethmoid sinuses and the secondarily involved maxillary. which allow drainage and ventilation. Anatomical variance of the middle turbinate. to the natural ostium by the mucous ciliary transport. as far as possible. disease spreads from the nose to the paranasal sinuses. whatever the cause. Similarly. frontal recess and posterior ethmoids may predispose patients to recurrent maxillary. which lies above and behind the ethmoid bulla. Persistent mucosal disease of the ethmoidal infundibulum. The emphasis of surgery is to preserve.e. These clefts are only a few millimetres wide and contain opposing mucosal surfaces lined with ciliated respiratory epithelium. Therefore anatomical variations. uncinate process and the ethmoid bulla are common. .FUNCTIONAL ENDOSCOPIC SINUS SURGERY Principle Most infections of the sinuses are rhinogenic. the ciliary beat activity may be impeded so that spaces are blocked and do not drain. are not thought to predispose to sinusitis. the cleft between the uncinate process and the middle turbinate. The anterior ethmoid sinus air cells and clefts are regarded as pre-chambers of the dependant frontal and maxillary sinuses. frontal and sphenoid sinuses. normal anatomy and to preserve mucosa. If extensive contact of opposing mucosal surfaces occurs. Disease of these pre-chambers may interfere with ventilation and drainage of the dependant sinuses and cause acute or chronic mucosal disease. which does not reline with ciliated respiratory epithelium. emphasising the importance of good surgical technique. disease of the posterior ethmoid sinuses may interfere with ventilation and drainage of the sphenoid sinus. while of academic interest. but usually a low columnella non-ciliated epithelium. frontal sinus and sphenoid sinus infection. The frontal and maxillary sinuses communicate with the nose through a complex system of narrow clefts. Mucosal stripping leaves exposed sinus bone. i. Endoscopic sinus surgery is minimally invasive surgery. between the ethmoid bulla and the middle turbinate. Scarring and non-ciliation may lead to an irreversible impediment of ventilation and drainage. Pathophysiology Mucus produced in the maxillary sinus is transported from the floor of the sinus along the sinus walls. The incidence of these variants is the same between a population with no history of sinus disease and a population with recurrent acute or chronic sinusitis. and in the lateral sinus.

particularly if primary surgery performed by inexperienced surgeons has caused a lack of anatomical land-marks. Endoscopic bipolar diathermy for posterior epistaxis. Certain patients may not benefit from endoscopic surgery. Sinus mycosis. Investigations A high definition CT scan of the paranasal sinuses on bone setting is required before undertaking endoscopic sinus surgery (except for the treatment of epistaxis). Polypoidal rhinosinopathy. Revision cases can be challenging. Patients should have agreed to surgery if the CT scan confirms this is necessary. Endoscopic arrest of CSF rhinorrhoea. significant scarring and narrowing of natural ostia due to mucosal stripping. Endoscopic drainage of an orbital abscess. Mucoceles. for example 1 or 2 mm coronal cuts of the frontal recess might be requested in difficult revision cases. but more extensive surgery. Chronic rhinosinusitis. In patients who have failed maximum medical therapy for recurrent acute or chronic rhinosinusitis or polypoidal rhinosinopathy. for example lateral frontal sinus mucoceles. A common protocol would be a coronal CT scan with 5 mm cuts of 1 mm thickness. Endoscopic pituitary surgery. Adjuvant surgery to allergy treatment. Antrochoanal polyps. Endoscopic orbital decompression. Variations from the standard protocol might be necessary from time to time. Endoscopic optic nerve decompression. with two axial cuts to allow the orientation of the internal carotid artery and optic nerve in the region of the posterior ethmoid and sphenoid sinus to be identified. Extended applications • • • • • • • Endoscopic spheno-palatine artery ligation for epistaxis. a CT scan should be requested to confirm that there is persistent disease amenable to endoscopic sinus surgery (the scan will provide details of sinus anatomy and disease extent). Surgical technique Surgery limited to the anterior ethmoids may be performed under local anaesthetic with topical vasoconstriction and sedation. Extensive experience and expertise is necessary in basic endoscopic sinus surgery before training in extended applications is undertaken. These include those with malignant sino-nasal tumours and those with inaccessible lateral frontal sinus disease. for example frontal recess surgery and posterior . Endoscopic dacryocystorhinostomy. most commonly for dysthyroid eye disease.110 OTOLARYNGOLOGY Indications for endoscopic sinus surgery • • • • • • • • Recurrent acute rhinosinusitis.

• Nasolacrimal duct injury. or if this is not available then stop the operation. in the unwary. It is much better to complete the surgery with a second stage procedure than to cause a major complication at the initial procedure. It may. Although it is an extremely efficient way of clearing soft tissue disease. due to intra-operative bleeding. Complications may be reduced by a thorough understanding of sinus anatomy. Many complications occur due to not recognising sinus anatomy. The aim of surgery is to re-establish ventilation and drainage of the affected paranasal sinus group. • Injury to structures impinging upon the lateral sphenoid sinus wall. Attendance at a post graduate course would be of considerable benefit to those who are novices in endoscopic surgery. The majority of experienced endoscopic surgeons in the UK have both through cutting instruments and the microdebrider to hand during surgery. The microdebrider cleanly cuts and aspirates tissue suctioned into the debrider opening. Surgery is performed in a stepwise manner from front to back (Messerklinger technique) or from the sphenoid forward (Wigand technique). Immediate post-operative • Intraorbital bleeding. Per-operative • Anaesthetic reaction. but has not yet learned the finer points of anatomy. Complications Complications of endoscopic sinus surgery may be life threatening or cause significant long term morbidity to patients. The inexperienced surgeon should be closely supervised by an experienced endoscopic sinus surgeon. and in particular polypoidal rhinosinopathy. Through-cutting instruments which cleanly cut through mucosa and bone of sinus air cells. • Epistaxis. • Penetration of the lamina papyracea to cause periorbital bruising or an orbital injury such as a medial rectus or an optic nerve injury. cause disastrous orbital injuries by rapidly sucking and debriding the orbital contents if the lamina papyracea is breached. • CSF leak due to penetration of the skull base. or when to stop during a procedure. Major complications are particularly likely to happen once the surgeon has gained some confidence and experience in the technique. 1. In experienced hands the micro-debrider can be used for a complete sphenoethmoidectomy. its detractors claim its usefulness for bone work is not proven as it may cause excessive scarring. Blindness and diplopia from per-operative complications will only become apparent on patient waking. • Bleeding. 2. . and prevent avulsion and stripping of mucosa are a recent advance. or to working in a poor surgical field. If the surgeon is uncertain as to the anatomy. or cannot visualise landmarks due to bleeding. namely the internal carotid artery and optic nerve. then he should ask for advice.FUNCTIONAL ENDOSCOPIC SINUS 111 ethmoid surgery requires a general anaesthetic. extensive cadaver dissection and observation of experienced surgeons in the surgical technique.

Management of major complications 1. • Intracranial infection (meningitis. brain abscess). Early post-operative • CSF leak (sometimes an unrecognised intra-operative complication). Follow up and after care Epithelialization of the ethmoid cavity is usually complete within 3 or 4 weeks of surgery. Tisseel glue may be used to obtain a good seal with a piece of silastic used to separate the graft from intranasal packing. Intraorbital bleed. but the commonest methods are using a middle turbinate flap. to allow the orbital contents to flow laterally and anteriorly. • Sequelae of per-operative and early post-operative complications. Most would advocate an external ethmoid approach to the anterior ethmoid artery which is diathermied or ligated. There are many techniques described to arrest the CSF leak. as in these circumstances there will be no soft tissue attachments preventing the artery from retracting into the orbit. An endoscopic medial approach is an alternative for the experienced.112 OTOLARYNGOLOGY 3. or a free turbinate graft to plug the defect. Late complications • Intranasal adhesions. or to use temporalis fascia and muscle. 2. • Recurrent disease. This will allow orbital fat and soft tissues to herniate into the ethmoids and will also provide drainage for any continued bleeding. The lamina papyracea is removed and a formal orbital decompression performed with incision of the orbital septum as for dysthyroid eye disease. If the leak is identified at the time of surgery then the site of the leak should be confirmed and the leak arrested. It has been recommended that a lateral canthotomy be performed. A lumber drain is usually unnecessary. or between the lateral nasal wall and nasal septum. Endoscopic orbital decompression has the dis-advantage of making identification of the bleeding anterior ethmoid vessel more difficult should a subsequent search be made for the vessel via an external approach. However. which is left in situ for several days. it can be removed endoscopically. CSF rhinorrhoea. and rapid decompression of the orbit is ne-cessary to save the patient’s vision. between the middle turbinate and septum. This is one of the most feared complications of endoscopic sinus surgery and occurs when the anterior ethmoid artery has been divided during surgery and retracts into the orbit while continuing to bleed. 4. Most surgeons now feel that this delays mucosal healing and removal of adherent crusts may predispose to greater scarring by . A CSF leak is the commonest major complication of endoscopic sinus surgery. perhaps with division of the orbital septum in the lower lid. Since the surgeon has already performed an ethmoidectomy and the lamina papyracea is exposed. Some authorities still propose de-crusting of the ethmoid cavity every few days following surgery. It is most likely to happen when the artery is divided when lying within a bony canal running from the orbit to the anterior cranial fossa. particularly within the ethmoidal cavity. An intra-orbital bleed caused by such an event will cause the eye to rapidly bulge and become tense. most surgeons will not have seen nor performed this procedure before and with a patients vision in immediate danger it is arguably not the time to start.

to remove nasal crusts and secretions is advised. the sphenoid sinus and the skull base. p. Further reading Zweig JL. Bhuta T. Sillers MJ. Rhinol 2000. This perception may change if a system is developed which can be set up rapidly in theatre or if medico-legal developments make it a requirement. 11. J. 6:449–455. Microdebrider technique: implications for endoscopic sinus surgery. It can locate the frontal sinus ostium. Sinusitis.. 174. 285. Imageguided transnasal endoscopic surgery of the paranasal sinuses and anterior skull base. Post operative steroids and antibiotics may be indicated depending on the surgeon’s preference and the underlying disease process. J. p. Yang F. Post operative nasal douching. Am. This usually allows the ethmoid cavity to heal and to become crust-free at 2 weeks post surgery obviating the need to remove persisting crusts. Pasquale—Niebles K. This system will be of especial use in patients with difficult anatomy and in revision cases. Nasal polyps. morning and night. Future developments The past three years has seen major advancements in the development of image guidance systems which provide three-dimensional images of the location of a probe within the sinuses. Barnes EL. Rhinol 1999. Am. Its application is currently not justified for routine endoscopic work.FUNCTIONAL ENDOSCOPIC SINUS 113 causing delayed healing. Schaitkin BM. 1:27–33. p. . Related topics of interest Allergic rhinitis.Neuman AM.

Disorders of motor function have certainly been demonstrated in globus patients. What is undisputed is that globus patients have much higher levels of psychological distress (than the general population) in the form of anxiety. This can be very rewarding to treat with a local anaesthetic/steroid injection. In this group of patients a vicious cycle is created where somatic concern and anxiety only serve to further aggravate the symptom. but there is still debate as to whether these are primary or secondary phenomena. In particular. usually in their fifth decade. for many the symptom actually improves during feeding. discomfort or foreign body in the throat for which there is no obvious cause. the two most strongly supported are the suggestion that it represents a manifestation of reflux oesophagitis or is a disorder of pharyngeal and oesophageal motility. usually at the region of the sternal notch. although it may be felt higher and to be unilateral. globus hystericus) is the sensation of a lump. which is what many of these patients are most concerned about. . This cycle of events is very similar to that seen in tinnitus and thus may represent another disorder of perception. Many people suffer from globus sensation for whatever underlying reason at some time in their life. Occasionally tenosynovitis of the digastric tendon as it runs through its sling on the hyoid may be the cause. including elevation of cricopharyngeal sphincter pressure. although one must be alert for any physical cause for the symptom such as a foreign body or an inflammatory cause. Pharyngeal pH measurements tend to be normal in such patients. Physical examination is normal. mid-oesophageal dysmotility and poor lower oesophageal sphincter relaxation. It is the patient’s psychological profile that dictates whether it becomes a problem. The complaint is typically of a lump in the throat. a neoplastic lesion should be excluded. The sensation is often intermittent and variable in severity. somatic concern. true difficulties are never a feature. neuroticism and even depression. Pathophysiology A number of organic aetiological theories have been proposed. Clinical features Patients are more often women. Many patients seem anxious and introspective. Although patients may complain of some subjective difficulty in swallowing.GLOBUS PHARYNGEUS Globus pharyngeus (globus syndrome.

p. 1992. Reflux oesophagitis should be treated with antacids. Further reading Wilson JA. endoscopy is indicated. Smoking should be discouraged. Globus sensation. Management There is no specific treatment for globus pharyngeus. 17:105–106.g.g. Pharyngeal pouch. Clinical Otolaryngology. Related topics of interest Hypopharyngeal carcinoma. Antidepressants may be required for those patients who are clinically depressed. Strong and appropriate reassurance at all stages is invaluable. Ambulatory pH measurement and manometry are sometimes used although they rarely add much to the clinical picture. H2 antagonists (e. Follow-up and aftercare Most patients are happy once reassured that they do not have cancer or other serious pathology. p. and followup is not usually required. lansoprazole or omeprazole).GLOBUS PHARYNGEUS 115 Investigations Most clinicians would perform a chest radiograph and a barium swallow in spite of a typical history and a normal clinical examination and the likelihood that these will be normal. In those patients with persistent or suspicious symptoms. 246. 124. Relaxation therapy can be suggested for those who are tense and over-anxious. ranitidine) or a proton pump inhibitor (e. . The radiologist should be encouraged to pay particular attention to the hypopharynx during the examination.

HALITOSIS

Aetiology and pathophysiology Halitosis is a problem that not uncommonly presents to the ENT surgeon and may be subjective or objective. The causes can be divided into three broad categories: local, general and drugs. Local and general causes overlap when general or systemic conditions give rise to a dry mouth. 1. Local causes. Saliva plays a crucial role in the oral cavity and is involved in taste, lubrication, water balance and oral hygiene. Saliva acts as a mechanical cleansing agent, its contained buffers combat acid/ alkali excesses and the secreted immunoglobulins have an important anti-infective function. Any significant reduction in salivary flow allows an increase in the local bacterial flora. These micro-organisms break down proteins with the production of odiferous volatile gases and consequent halitosis (as well as leading to an increase in dental caries and periodontal disease, in themselves a cause of halitosis). A decrease in saliva production can occur temporarily, as during sleep and with anxiety, or more permanently as a result of previous radiotherapy, cardiac and renal failure and some autoimmune conditions (Sjögren’s syndrome). Any local inflammatory lesion is likely to become secondarily infected and lead to halitosis. Examples include any oral ulcerative lesion (from aphthous to neoplastic), tonsillitis, pharyngitis and nasal and sinus infections. 2. General causes. Certain foods, alcohol and cigarettes all give rise to a characteristic unpleasant smell on the breath. A reduction in food intake during any systemic illness will lead to ketosis and typical ketotic breath. Diabetes can lead to a sweet acetone smell, uraemia a smell of ammonia, liver failure a smell of decaying blood and chest infections a peculiarly foul anaerobic smell. The latter is particularly common in bronchiectasis. Reflux of partially digested stomach contents into the oesophagus as a result of hiatus hernia is another cause. There are some patients who complain bitterly of halitosis for which there is no objective support. This may represent a monosymptomatic hypochondriacal condition, and these patients may be severely depressed. 3. Drugs. Drugs can cause halitosis by several mechanisms: they may cause a dry mouth (anticholinergics), they may alter the normal oral and pharyngeal flora (antibiotics) or their metabolites may be excreted by the lungs (chloral hydrate, iodine-based medications). Clinical features Halitosis is usually due to local causes. It is commonest in those with poor dental hygiene and peridontal disease. There is a natural decline in salivary flow and increase in dental disease with age. A full history should be taken to establish any possible systemic or drug causes. Clinical examination should establish

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objective evidence of halitosis. A useful manoeuvre is to ask the patient to breathe through the mouth and the nose separately; if the smell is still present when breathing through the nose, an extraoral cause should be suspected. Investigations Investigations should be directed at the suspected cause and might include a chest radiograph and blood tests to exclude systemic disease. Management Management should obviously be directed at the underlying cause and will often fall outside the remit of the ENT surgeon. Those with systemic causes and severe chest disease will require referral to an appropriate physician. Patients with a psychological problem may require referral to a psychiatrist. Periodontal disease will require the services of a dental practitioner. Most oral inflammatory conditions will resolve spontaneously, but any that persist demand biopsy and subsequent definitive treatment. Pharyngitis, tonsillitis and sinonasal disease can all be treated appropriately by the ENT surgeon. General advice on adequate dental care, good fluid intake should be given. In some patients with objective halitosis and little pathology, a lengthy (2 to 3 months) trial of low dose antibiotics to alter the local bacterial flora can be helpful. Follow-up and aftercare This will be dictated by the underlying cause. Further reading
Symposium on dry mouth and halitosis. The Practitioner, 1990; 234:603–619.

Related topics of interest Sinusitis, p. 285; Intrinsic rhinitis, p. 131; Tonsil diseases, p. 330.

HEARING AIDS

A hearing aid is any device that amplifies sound or assists the hearing-impaired individual, but in the present context will be taken to mean an electro-acoustic device used to amplify sounds. Cochlear implants can be included in this definition, but they are described in a separate topic. Design It is important to be familiar with the basic design of the hearing aid as many patients attending the ENT department are prescribed them. There is a good chance you will be handed one and asked to describe it in an examination. The basic components of any hearing aid are a receiver (microphone and/or induction coil), an amplifier/ processor, a sound transmitter (earphone, bone conductor) and a power source (primary cell). There are two types of signal processing systems—analogue and more recently digital. 1. Analogue systems. In analogue systems, an acoustic signal is converted to its electrical analogue at the microphone stage of the hearing aid circuit. That is, an acoustic signal is constantly varying in sound pressure. When converted to an electrical analogue, the varying sound pressure is changed to a varying voltage. The amplitude of these voltages can be controlled so as to emphasize selected frequency regions, as well as carrying out other processing tasks. In order to avoid the problem of excessive amplification of loud sounds which may cause discomfort to the user, analogue amplifiers can use one of two methods of reducing sudden peaks of sound. (a) Peak dipping. In essence this system basically chops the tops off the peaks of sound. It has the advantage of being simple and instant but does result in some distortion. (b) Automatic gain control This system involves some complicated circuitry that picks up the signal and compresses it so that the maximum sound peak is never above a set maximum value. It is a little more complicated but produces less distortion. The external controls are usually a selector switch and a volume control. The selector switch has three markings; O is for off, T is for a television or telephone induction coil and M is for the microphone. Internal controls on the amplifier/processor are often available to alter the frequency response and spread of volume control available to the user. Some analogue aids can now be digitally programmed to alter their processing performance. 2. Digital signal processing. Digital is best defined as sound that is represented mathematically. When digital signal processing (DSP) is used, the acoustic signal is converted to its electrical analogue at the microphone stage of the hearing aid system. After this conversion, a frequency filter is introduced to reduce

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possible distortion of the input signal, which is then sampled a defined number of times per second (normally, 10 000 times per second or greater). The analogue signal is then converted to its digital equivalent at the analogue to digital stage (A/D). Each of the samples receives a digital code. Binary numbers (0 and 1) are used to represent the digital value of each sample. Following the digitization of the signal, the digital representations are processed by a central processing unit (CPU) or microprocessor. The digital values can be multiplied, divided, added, subtracted and grouped in defined ways. In the microprocessor are various algorithms. For example, one algorithm may control the frequency response of the instrument, another may control loudness growth, a third may function to enhance the speech signal in a background of noise, etc. After the microprocessor has performed its tasks, the digitized signal must be converted back to its analogue equivalent. This is accomplished at the digital to analogue conversion stage (D/A). It is then again frequency filtered and amplified in the conventional manner and submitted to the ‘loud-speaker’ of the hearing aid. The obvious advantage of digital signal processing is that there are unlimited ways in which the signal can be manipulated. The numbers of parameters that can be utilized are significantly greater than those found in conventional analogue systems. As such, the ability to manipulate the signal to the acoustic needs of the patient is greatly enhanced, and this without excessive battery current demands. Types of aid As things currently stand most NHS aids are analogue in design. However the government have recently announced a ‘Beacon Site project’ to look at the logistics and feasibility of providing digital hearing aids through the NHS. Most digital aids are the same basic design as NHS aids, but as the DSP ‘chip’ is so much smaller than the corresponding analogue circuit they tend to be smaller and are often ‘in the ear’ (ITE) or even ‘in the canal’ (ITC) aids. 1. Postaural aids. In most common usage are the standard behind-the-ear (BEHA) aids, available on the NHS. The body of the aid sits behind the wearer’s ear and is normally connected by a hollow plastic tube to an ear mould, which allows sound passage to the ear. There are three main groups of BE aids, the 10, 30 and 50 series, with the power of the aids increasing correspondingly. Within each series are a number of models with differing patterns of frequency response. All contain an induction coil which can be used with telephones, televisions and in theatres and cinemas, fitted with induction loops, to bypass much of the unwanted back-ground noise. 2. ITE or ITC aids. These commonly available commercial aids sit in the concha or canal. Their external shell is usually of acrylic and conforms to the shape of the wearer’s ear. They are less obtrusive than the standard BE aids but are expensive and occasionally prone to feedback problems due to the proximity of microphone and ‘speaker’. 3. Body-worn (BW) aids. These rather cumbersome, ugly aids are usually worn with a strap around the neck and the body of the aid on the patient’s chest. By virtue of their size they can be made very powerful, and the distance between microphone and earphone means that, even with high amplification, feedback is rarely a problem. They are, however, prone to picking up the sounds of rustling clothes. There are two series available on the NHS: BW 60 and BW 80. 4. Bone conduction aids. These are very similar to the standard body-worn aid but feed their output to a bone conductor rather than an earphone. They are indicated because of meatal discharge or stenosis, or subjective preference for bone conduction reception. 5. Osseointegrated hearing aids. Conventional bone conduction aids have drawbacks, such as bulkiness and discomfort. In addition, the skull cannot be vibrated directly, but only through the energy-absorbing

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skin and soft tissues. Bone-anchored hearing aids largely overcome these problems. There are two devices in clinical use, both relying on the transmission of mechanical vibrations to the bone of the skull. (a) In the bone-anchored hearing aid (BAHA) a percutaneous titanium abutment is fixed to a titanium screw implanted in the mastoid. A vibrator is then mounted directly on to the abutment, which is fed either from a microphone and circuit in a small box with the vibrator or from a body-worn hearing aid (for higher output power). (b) The Xomed audiant bone conductor consists of an encased rare earth magnet implanted completely under the skin and fixed into bone with a titanium screw. Externally, another magnet serves to hold its surrounding induction coil in place over the implanted magnet. By passing electric currents (derived from what is essentially a hearing aid) through the induction coil, an electromagnetic field is set up that causes the implanted magnet, and hence the skull, to vibrate. 6. Implantable middle ear aids. The Symphonix sound bridge works on a similar principle to the Xomed audiant except that the external magnet vibrates a coil that is attached to the patient’s incus, thus directly vibrating the ossicles. 7. Spectacle aids. These involve modification of standard spectacle frames to incorporate a hearing aid. They can then be used in a number of ways: as a standard hearing aid, as a bone conductor or for contralateral routing of signal (CROS). In this last variation, sound is picked up from one side of the head and fed to the contralateral side, which is often the good side. Choice of aid Many factors will influence the choice of hearing aid. The actual degree and nature of the hearing loss will dictate the amplification characteristics. The cause of the deafness will influence the type of aid chosen, as will vanity and available finance. It is important to establish the patient’s requirements and to remember that an aid will not cure the underlying disease. 1. Type. A spectacle-type aid is useful for those people who regularly wear glasses as they are relatively inconspicuous. They are often chosen when there is one very deaf ear and a requirement for contralateral signal routing. A bone conduction aid is ideal in those cases where a hearing loss exists in association with active outer- or middle-ear inflammatory pathology. A body-worn aid is useful for anyone with a profound hearing loss. For most NHS patients an ear-level aid will be found to be suitable. 2. Amplification characteristics. The pattern of frequency response chosen depends very much on the shape of the audiogram. As for amplification, a hearing aid must function in a relatively narrow dynamic range, providing adequate amplification to overcome the hearing loss, but not over-amplifying sound and causing recruitment and consequent discomfort and intolerance. In an effort to overcome this problem, a number of formulae have been developed to calculate the appropriate amplification for the patient’s hearing loss (half-gain rule, Berger’s procedure, POGO 2, NAL-R, etc.). All formulae give differing importance to differing frequencies, with maximum importance for hearing loss at the main speech frequencies of 1000 and 2000 Hz. Many patients with deafness have a high frequency loss with comparative sparing of the lower frequencies. Most hearing aids can be adjusted to alter their frequency response, for instance high tone boost and base tone cut. More flexibility exists with digital signal processing. 3. Ear moulds. A number of modifications can be made to the ear mould. These may be made for both auditory and medical reasons. Venting the mould will reduce the low-frequency response. In patients prone

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to otitis externa, it is useful to ventilate or even skeletonize the mould to provide aeration. Unfortunately, feedback becomes more likely with a high-power aid if the mould is vented. 4. General. Although it is preferable to provide binaural aids in cases of bilateral hearing loss, this is rarely possible in the NHS on the grounds of cost, although the National Institute for Clinical Excellence (NICE) have recently endorsed this approach. Which ear to fit the aid in will then depend on a number of factors, including patient preference, available dynamic range and discrimination scores in each ear. The presence of any active inflammatory process in either ear, as well as other medical factors such as manual dexterity relating to arthritis, strokes, amputations, etc. also have a bearing. Follow-up and aftercare After the initial fitting, a period of support and rehabilitation is essential to allow the patient to gain confidence, iron out early teething troubles and achieve useful function with the hearing aid. In fact some would argue that this process is more important than the aid itself. Further reading
Ballantyne D. Handbook of audiological techniques. London: Butterworth-Heinemann, 1990. The Hearing Aid revolution. ENT News, Jan/Feb 2000, Volume 8(6). National Institute for Clinical Excellence. Technology appraisal guidance No. 8. Guidance on hearing aid technology, July 2000.

Related topics of interest Noise-induced hearing loss, p. 192; Presbyacusis, p. 252; Otosclerosis, p. 223; Pure tone audio-gram, p. 254.

HIV INFECTION

Aetiology Acquired immunodeficiency syndrome (AIDS) is caused by two of five human retroviruses: human immunodeficiency viruses (HIV) 1 and 2. (The other three are T-cell leukaemia viruses and are associated with lymphomas and leukaemias.) Pathology HIV-l is prevalent worldwide, while HIV-2 is found mainly in west Africa. HIV infects cells bearing the CD4 antigen, which acts as a virus receptor. Such cells are monocytes, macrophages and T-helper cells. The HIV-1 glycoprotein, gp120, binds to CD4 and allows the virus to enter the cell. Viral replication may occur in cells in which HIV-1 DNA has been integrated (productive infection), although in some cells containing integrated HIV-1 DNA, the virus does not replicate except when the cell is activated by antigenic stimulation (latent infection), for example by Epstein-Barr virus or cytomegalovirus infection. Ultimately, a functional impairment and depletion of T-helper cells occurs, but to a degree that is disproportionate to the number of cells infected. The mechanism of this has yet to be elucidated, but may relate to damage to lymph node architecture. The ultimate consequence is a compromise of the host immune system. Immunosuppression places the victim at risk of developing opportunistic infections and unusual malignancies, particularly B-cell lymphoma and Kaposi’s sarcoma. Clinical features AIDS is defined as the development of a complication of immunosuppression such as malignancy or opportunistic infection in an HIV-positive individual. The CD4+ T-cell count will be less than 200/mm3. Although the time to development of AIDS is variable, the majority of infected individuals in developed countries will develop AIDS about 10–11 years after infection with HIV, in the absence of treatment. So far only about 2% of infected individuals have avoided progression to AIDS. It is invariably fatal, with nearly two-thirds of reported sufferers in the USA already dead. There are various methods of transmission, but all demand close contact with infected body fluids, particularly blood. High-risk groups include intravenous drug users, homosexual males, heterosexual contact with an infected partner and children of infected mothers. Although transfusion of blood products, particularly in haemophiliacs, resulted in a significant number of cases, the screening of all blood products for HIV-1 and HIV-2 antibody has greatly reduced but

Neck abscess may occur and tend to be deep. are usually between the ages of 20 and 40. followed by western blot confirmation. They often culture unusual organisms. Generalized cervical lymphadenopathy is a frequent finding in all AIDS patients. Kaposi’s sarcoma and lymphomas may be found in the nasopharynx. The CD4+ T-cell count is less than 400/mm3. Plasma HIV RNA assays give useful information when measured sequentially about both disease progression and response to anti-viral treatment. ENT disorders and HIV infection Between 40 and 70% of patients will have head and neck manifestations. Kaposi’s sarcoma of the pinna or external auditory meatus may occur. Opportunistic infections are diagnosed by appropriate sampling and microbiological culturing. radiology) are dictated by the clinical conditions. 2. Otological.HIV INFECTION 123 not irradicated the risk because it may take up to 4 months for seroconversion (the interval between infection and the appearance of antibody). weight loss. Salivary glands may enlarge. Kaposi’s sarcoma is not uncommon. Management The management of HIV infection as it presents to the ENT surgeon and the management of the patient so as to avoid the risks of infection pose separate problems. Radiotherapy and chemotherapy may be used for Kaposi’s sarcoma and lymphomas. The oral cavity is one of the most commonly affected sites. Otitis media and externa (particularly fungal) are more common. Herpes simplex ulceration is also common and tends to be widespread and severe. Other investigations (e. To reduce this risk. Severe candidiasis is frequent and may spread to involve the pharynx and larynx. Neck. Monitoring of the CD4+ T-cell count is helpful as a surrogate measure of immune function. Neoplastic lesions are confirmed histologically on biopsy. Xerostomia is a frequent complaint and epiglottitis is reported to occur more often. Chronic rhinosinusitis may occur because of the debilitated state of the patient. Investigations The diagnosis of HIV infection depends on detecting the virus or the host response to it in the blood. anaemia and diarrhoea. Acute sinus infections may occur and unusual organisms such as yeasts and fungi are not uncommon. Oropharyngeal. Risk of infection The risk of infection to a health care worker from an HIV-positive patient is extremely low and invariably relates to blood exposure. The occurrence of unusual organisms requires a high index of suspicion to make the diagnosis followed by appropriate therapy. two sets of common sense recommendations have developed.g. using first an enzyme-linked immunosorbent assay (ELISA) as a screen. e. AIDS-related complex (ARC) comprises persistent fever lasting longer than 3 months. Rhinological. atypical mycobacteria. Usually this is done by identifying a specific antibody. leucopenia. excluding children.g. Typical patients are in one of the high-risk groups and. 4. 3. . AIDS patients are prone to a variety of conditions: 1.

p. 305:1337–1343. 115. Joint Working Party of the Hospital Infection Society and Surgical Infection Study Group. Risk to surgeons and patients from HIV and hepatitis: guidelines on precautions and management of exposure to blood or body fluids. Medical Clinics of North America. p. 209. 271. Salivary gland diseases.124 OTOLARYNGOLOGY • Universal precautions should be adopted for all patients and involve the use of gowns and gloves to avoid blood contamination. . Should inoculation occur. Sinusitus. 75:1389–1399. Non-Nucleoside (NNRTI) and Nucleoside Analogue (NARTI) Reverse Transcriptase Inhibitors. p. Otolaryngologic aspects of the acquired immunodeficiency syndrome. but the theatre should be thoroughly cleaned with hypochlorite solution prior to the next case. The most senior or experienced surgeon/clinician should operate and theatre/ancillary staff should be kept to a minimum. and for other HIV infected individuals. Related topics of interest Cervical lymphadenopathy. p. 1992. 1991. British Medical Journal. Generally ‘triple’ therapy is recommended to avoid drug resistance in a very similar fashion to treatment of tuberculosis. There is no evidence of infection risk from the anaesthetic system. Otitis externa. 76:1–18. Halitosis. Lucente FE. 29. HIV-1 infection: diagnosis and management. Follow-up and aftercare In general terms these patients are best cared for in a centre with a team with a particular interest in AIDS. Current effective antiviral agents include Protease Inhibitors (PI). The patient need not be last on the list. Further reading Gold JWM. • Theatre precautions apply to any invasive procedure on a proven or suspected HIV-positive patient. Drapes should be disposable and double bagged at the end of the procedure. Appropriate serological monitoring is then required over a period of several months. All non-intact skin surfaces should be covered and sharps should be handled with appropriate caution. Medical Clinics of North America. p. All staff should be fully gowned and double gloved and boots and eye protection should be worn. A high level of discipline is required in these cases. combination therapy may be used. but sensible hygienic measures should be employed. 285. 1992. The General Medical Council recommends that a HIV-positive clinician should not perform invasive procedures.

but the piriform fossa (60%) is the most common site. For the purposes of tumour classification the UICC recognizes three anatomical sites: 1. angular stomatitis. causing fixation of the vocal cord and consequent hoarseness. Posterior pharyngeal wall Extends from the level of the floor of the vallecula to the level of the inferior border of the cricoid cartilage. but they are rare.HYPOPHARYNGEAL CARCINOMA The hypopharynx extends from the lower limit of the oropharynx at the level of the hyoid bone down to the lower level of the cricoid cartilage at the opening of the oesophagus. Other epithelial and mesodermal tumours of benign and malignant behaviour do occur. 3. whereas an ulcerated lesion is typical of the other parts of the hypopharynx. In the postcricoid site the reverse is true. Dissemination of hypopharyngeal tumours in the submucosal lymphatics leads to a high incidence of ‘skip lesions’. Medial wall tumours invade the aryepiglottic fold and into the paraglottic space. koilonychia and splenomegaly) will develop postcricoid carcinoma. glossitis. pharyngeal web. This extends from the pharyngoepiglottic fold to the opening of the oesophagus. Tumours of the lateral wall of the piriform fossa may invade the thyrohyoid membrane and present as a palpable neck mass which may represent direct extension of the tumour rather than an enlarged lymph node. It is bounded medially by the aryepiglottic folds and laterally by the inner surface of the thyroid cartilage. More than 10% of patients have a second tumour in the oesophagus. Tumours of the posterior pharyngeal wall and the upper piriform fossa tend to be exophytic. Approximately 2% of patients with the Paterson-Kelly-Brown syndrome (iron deficiency anaemia. Postcricoid (The pharyngo-oesophageal junction). 2. A few patients who had irradiation for thyrotoxicosis many years ago are now presenting with pharyngeal carcinoma after a latent period of 25–30 years. the association is not as clear as with other upper aerodigestive tract tumours. Pathology More than 90% of tumours of the hypopharynx are squamous cell carcinoma. Hypopharyngeal tumours are sometimes so advanced when first seen that it is difficult to determine the site of origin. Hypopharyngeal tumours also have a propensity to metastasize to cervical . Extends from the level of the arytenoid cartilages and connecting folds to the inferior margin of the cricoid cartilage. Although tobacco smoking and alcohol have been implicated as aetiological agents. thus forming the anterior wall of the hypopharynx. Piriform fossa. Carcinoma of the hypopharynx in itself is an uncommon disease with a prevalence of less than 1 per 100 000 population. with postcricoid carcinoma (30%) and posterior pharyngeal wall tumours (10%) occurring less often. It is a disease of the elderly and the incidence is higher in men than in women.

T4 Tumour invades adjacent structures e. Radiography. and all patients should have their necks palpated again while they are under the general anaesthetic. Indirect laryngoscopy may reveal an obvious tumour or oedema of the arytenoids with pooling of saliva in the piriform fossa. at first for solids then for fluids. Every patient who presents with swallowing difficulty or the sensation of a lump in the throat should have a barium swallow. Management of the patient will depend on. The extent of the lesion. Digital examination of the tumour is appropriate if there is superior spread. MRI is preferable to CT scanning in delineating the extent and spread of tumour. The patient with advanced disease may have anorexia and weight loss.g. TNM Stage T1 Tumour limited to one subsite of hypopharynx and 2 cm or less in greatest dimension T2 Tumour invades more than one subsite of hypopharynx or an adjacent site. or measures 2–4 cm in greatest dimension. need to be assessed. A soft-tissue neck radiograph is of limited value. There may be a history of food sticking and repeated aspirations which will cause pneumonia. particularly its upper and lower limits. neck soft tissues. Investigations 1. with half of these being bilateral. or with fixation of the hemilarynx. Later the patient will usually present with dysphagia. Direct laryngoscopy and oesophagoscopy should be performed in every patient who has an abnormal barium swallow or persistent symptoms despite a normal barium swallow. 3. among other factors. Hoarseness may occur as a result of invasion of the larynx or vocal cord paralysis. A full blood count to exclude anaemia and biochemical tests are required as electrolyte disturbances are not infrequent. The piriform fossa has the richest lymphatic drainage. Bronchoscopy should be performed to look for any spread to the trachea. Postcricoid tumours have a tendency to spread to paratracheal nodes. and/or oesophagus. A chest radiograph is mandatory to exclude metastases and to demonstrate any consolidation due to aspiration. and more than two-thirds of these patients will have lymph node metastases at presentation. T3 Tumour measures more than 4 cm in greatest dimension. There may be vocal cord fixation. This allows staging of the tumour and a representative biopsy to be taken. Laryngeal crepitus is lost in post-cricoid tumours and occasionally a direct extension of the tumour through the thyrohyoid membrane is palpable. Endoscopy. . prevertebral fascia.126 OTOLARYNGOLOGY lymph nodes. thyroid/cricoid cartilage. which will usually demonstrate the presence and extent of any hypopharyngeal tumour or oesophageal lesion. Laboratory tests. Clinical features Early symptoms include the sensation of a lump or discomfort in the throat. the site and extent of the disease. The neck must be examined for lymph node metastases. 2. but it may show a shadow posterior to the trachea. This can be regarded as abnormal if it is wider than the thickness of a vertebral body.

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Management Hypopharyngeal carcinoma generally has a poor prognosis even with extensive surgery, and 60% of patients are dead within a year of diagnosis. Because of the low survival and high recurrence rate the choice of treatment is particularly important. The optimal treatment modality should provide the best chance of cure, the lowest mortality and morbidity, the shortest hospital stay and the highest chance of good upper aerodigestive tract function (speech and swallowing). All patients should have some treatment to their neck. In patients with an NO neck the overall risk of occult nodal metastases may be as high as 40–60%. Bilateral nodal involvement is common. Therefore treatment of both sides of the neck and the retropharyngeal lymph nodes with either surgery or radiotherapy must be considered electively. Metastases are most common in levels II, III and IV. A lateral selective neck dissection is therefore appropriate if surgery is the preferred modality. Treatment may consist of radiotherapy, surgical resection, combined therapy or palliative therapy. 1. Radiotherapy. Early hypopharyngeal cancer may be treated with radiotherapy, with the option of salvage surgery if there is a recurrence. Radiotherapy may be reserved for the patient without enlarged lymph nodes, but it has been proposed that in selected cases radiotherapy can be given to the primary tumour and a radical neck dissection carried out for nodal metastases. 2. Surgery. Surgical resection is preferred for large tumours or in the presence of bulky cervical metastases. A lateral pharyngotomy can be performed for posterior wall tumours and the defect repaired with a radial forearm free flap. Extensive and circumferential lesions will require total pharyngolaryngectomy and then reconstruction of the residual defect. A variety of techniques to reconstruct have been used including skin grafts, cervical and deltopectoral skin flaps, myocutaneous pectoralis major and latissimus dorsi flaps and visceral interposition of stomach, jejunum or colon. The main complications are failure of the graft or flap, postoperative fistulae and stenosis, which are all more likely if there has been previous radiotherapy. There is also a significant mortality rate of 1% for skin flaps and revascularized loops and up to 10% for gastric transposition. The choice of reconstruction depends largely on the experience of the unit. 3. Combined therapy. Postoperative radiotherapy is carried out within 6 weeks of surgical resection as a combined treatment, with the aims of destroying metastases and maximizing the recurrence-free life interval. It is indicated if: surgical resection margins are close to or involved in tumour, in most large tumours requiring surgery, when there is vascular or perineural invasion, more than 2 lymph nodes are involved, or if there is extra-capsular rupture. 4. Palliation. This therapy is for those patients with advanced end-stage disease, severe intercurrent illness, poor general condition, distant metastases, or those who refuse treatment. Palliative radiotherapy can be offered to produce tumour shrink-age and symptom relief in some cases. Follow-up and aftercare On the 10th postoperative day, if there is no evidence of graft failure or leak, the patient can be tested with a methylene blue or gastrograffin swallow. If there is no evidence of extravasation, the patient can be commenced on fluids and then soft diet. Most patients will require thyroid, calcium and calciferol replacement for life. Speech rehabilitation is difficult in these patients, although there are some encouraging reports with low-pressure speech valves (e.g. Provox or Blom-Singer), the voice is not as good as after a total laryngectomy. Patients should be regularly reviewed in the clinic and their nutritional status and swallowing ability should be monitored along with a careful examination for primary and secondary recurrence.

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Further reading
Jones AS, Roland NJ, Husband D and Gati I. Free revascularised jejunal loop repair following total pharyngectomy for carcinoma of the hypopharynx, a report of 90 cases. British Journal of Surgery, 1996; 83:1279–1283. Schetter GL. Cancer of the hypopharynx and cervical oesophagus. Current Opinion in Otolaryngology and Head and Neck Surgery, 1998; 6:97–101. Wilson J (ed). Effective Head and Neck Cancer Management. Second Consensus. British Association of Otolaryngologists, Head and Neck Surgeons, 2000.

Related topics of interest Globus pharyngeus, p. 113; Laryngeal carcinoma, p. 138; Oral cavity carcinoma, p. 197; Oropharyngeal carcinoma, p. 203.

IMPEDANCE AUDIOMETRY

Physics and physiology The middle-ear and mastoid air cells communicate with the nasopharynx via the Eustachian tube. As a closed system, air is being continually absorbed by the lining mucosa but is periodically replaced when the Eustachian tube opens, during the act of swallowing. Sound transmission from the external to the inner ear is optimal when the compliance of the middle-ear system is maximal, i.e. when the pressure in the middle ear is equal to the pressure in the external auditory meatus. Compliance (or admittance) is the measure of this system to allow the passage of sound energy through it, and is inversely related to impedance, which is the resistance to the passage of sound energy. The mass, stiffness and frictional resistance of the medium through which the sound wave travels contribute to the impedance, which at low frequency is stiffness dominated. Strictly speaking, compliance is the reciprocal of stiffness so that impedance measurements at low frequency are usually referred to as the compliance. Basic principles Impedance audiometry consists of three tests: tympanometry, acoustic reflex testing and static compliance. All three tests work on the same basic principle. The test probe consists of a sound producer, a sound receiver and a device for altering the air pressure within the EAM. The probe has a soft plastic or rubber tip to allow an air-tight seal in the EAM. A test tone is made (220 Hz, 65 dB) into the EAM, of which some will be absorbed (admitted) by the middle-ear system (drum and ossicles) and some reflected. The reflected sound energy is measured by the probe microphone. The compliance, that is the amount of sound absorbed by the middle-ear system, can be determined either by measuring the reflected sound level in the ear canal or more commonly by measuring the amount of energy required to keep the sound level constant at varying ear canal pressures. The compliance will be maximal when the ear canal pressure is equal to middle-ear pressure, that is when there is no pressure differential across the tympanic membrane. A tracing of the compliance as ear canal pressure alters allows this and other parameters to be determined. Clinical uses 1. Tympanometry. This test is the most commonly used aspect of impedance audiometry and is particularly useful in evaluating children with otitis media with effusion. Here compliance is measured continuously while the pressure in the EAM is automatically varied from +200 to -400 mm H2O. This gives a graphical result which can be classified into one of three groups:

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(a) Type A. Maximal compliance occurs when the pressure in the EAM is between +50 and -100 mm H2O. A normal maximal compliance value is between 2 and 4 ml. A low value for maximal compliance indicates stiffness of the middle-ear system as in tympanosclerosis or otosclerosis. A high or unrecordable peak of compliance indicates excess mobility of the middle-ear system as in ossicular discontinuity or atelectasis. (b) Type B. A low-value flat or horizontal compliance trace occurs, implying persistently low compliance. This is usually taken to indicate fluid in the middleear cavity, and in young children (< 7 years) with glue ear can be correlated with audiometric hearing loss. A type B tympanogram will also occur in the presence of a perforation in the tympanic membrane but the ear canal volume will be large (> 6 ml) because it is measuring that of the middle-ear cleft too. It can occasionally be useful in confirming this diagnosis or to test the patency of a ventilation tube. (c) Type C. This group give a peak compliance when the pressure in the EAM is < -100 mm H2O. This indicates a significant low pressure in the middle-ear system and is a sign of eustachian tube dysfunction. The C curve can be subdivided into Cl, when the peak is between -100 and -199 mm H2O, and C2, when the peak occurs at less than -200 mm H2O. 2. Acoustic reflex measurement. Acoustic reflexes are measured at the ear canal pressure producing maximum compliance, which corresponds to middle-ear pressure. Ipsilateral reflexes are recorded using the tympanometry probe; contralateral reflexes use a monaural headset to deliver sound to the non-probe ear. It is usual to test at 0.5 kHz and then at either 1 or 2 kHz. A sound intensity of 70–90 dB above the pure tone threshold at that frequency is required to elicit a reflex in a normal-hearing subject, although in one who has a recruiting sensorineural hearing loss a reflex may be present only 10 dB above threshold. The compliance, which is constant for the ear canal pressure selected, is recorded as a horizontal line and shows a dip on contraction of stapedius muscle, representing a reduction in compliance. The stapedial reflex is a complex crossed reflex and demands an intact afferent arm, brain stem and VIIth cranial nerve. As such, the acoustic reflex can provide diagnostic information with regard to the site of a neurological lesion based on the pattern of response to ipsi- and contralateral testing. It is important to remember that a conductive hearing loss of only 5 dB may result in an absent ipsilateral and contralateral (for reasons that have not been satisfactorily explained) reflex, although it is not until there is a 15 dB air-bone gap that the reflex is absent in 50% of cases. Adaption (stapedial reflex decay) is determined by producing a persistent tone in the test ear and measuring the reflex in the contralateral ear. Normal adaption occurs only after 10 seconds, decay being no more than 50%. Summary of the value of measuring the acoustic reflex: (a) Assesses the integrity of the facial nerve up to the branch to stapedius tendon. (b) Assesses recruitment and stapedial reflex decay, the latter in particular being an accurate pointer in distinguishing a cochlear (recruiting) from a retrocochlear (abnormal decay) lesion. (c) Assess the presence of a conductive hearing loss. (d) Assess brainstem function. 3. Static compliance. The least used of the three tests. The compliance is measured with an air pressure of +200 mm H2O in the EAM, and this figure is subtracted from the maximal compliance, regardless of the pressure in the EAM at which this occurs. The normal range for this is from 0.3–1.6 ml. A figure greater than 2.0 ml implies the presence of a tympanic membrane perforation.

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Conclusion Impedance audiometry is rapid and easy to use. It provides an objective measure of middle-ear function, can help to distinguish cochlear from retrocochlear hearing loss, as well as localizing brainstem and facial nerve lesions. It is, however, essential that the results are interpreted in the context of other clinical findings. Further reading
Ballantyne D. Handbook of Audiological Techniques. London: Butterworth-Heinemann, 1990. Jerger J, Hayes D. Clinical use of acoustic impedance testing in audiological diagnosis. In: Beagley HA (ed.) Audiology and Audiological Medicine, Oxford: Oxford University Press, 1981.

Related topics of interest Acoustic neuroma, p. 1; Clinical assessment of hearing, p. 45; Facial nerve palsy, p. 92; Otitis media with effusion, p. 213; Pure tone audiogram, p. 254; Speech audiometry, p. 301.

INTRINSIC RHINITIS

Intrinsic rhinitis (IR) is an inflammatory condition of the nasal mucosa which is probably better described by the title non-infective, non-allergic rhinitis. As such it represents, to some extent, a diagnosis of exclusion. Pathology IR has been divided into two types, eosinophilic and non-eosinophilic, on the basis of the numbers of eosinophils found in the nasal secretions. However, recent research evidence has cast doubt on this distinction. It is likely that the condition represents more than one pathological process. Upsets to the autonomic nervous system have been postulated, but it would appear that immunological abnormalities are common. Of particular recent interest has been the separate findings of anti-IgE antibodies and elevated nasal IgE levels. A number of patients demonstrate an intrinsic mucosal disorder of prostaglandin metabolism. In this type there is an association with aspirin hypersensitivity, asthma and nasal polyposis. Regardless of the underlying aetiology most patients demonstrate glandular hyperplasia and submucosal vascular dilation. The nasal mucosa becomes hyperaemic and hypertrophic, particularly on the turbinates. Eosinophil-laden polyps are more common in IR than in allergic rhinitis. Predisposing factors • • • • • • • • • Familial tendency. Preceding infection (nasal mucosal hyper-reactivity following viral or bacterial rhinitis). Psychological and emotional factors. Endocrine (puberty, menstruation and pregnancy). Drugs (hypotensive agents, e.g. beta blockers and methyl dopa, aspirin, oral contraceptives). Pollution (atmospheric pollution, fumes, dust, industrial detergents and cigarette smoke). Atmospheric conditions (changes in humidity and temperature). Alcohol. Smoking. Clinical features IR accounts for 40–70% of all cases of perennial rhinitis and becomes more common with increasing age. All patients exhibit nasal obstruction and rhinorrhoea or post-nasal discharge, but itching and sneezing are less common than in allergic rhinitis. Patients vary in their degree of nasal obstruction and discharge. There may

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be associated nasal polyps with anosmia. Co-existent sinus pathology is frequently found (up to 50%) which may be primary, causing a secondary rhinitis, or secondary due to the inevitable compromise of sinus aeration and drainage. Examination generally reveals a rather red and angry mucosa, often with copious secretions and hypertrophy of both middle and inferior turbinates, causing a consequent reduction in the airway size. Investigations IR is a diagnosis of exclusion, and the aim of investigations is to identify other causes of rhinitis. IgE estimation by PRIST and RAST and skin testing can be used to indicate allergy. Radiological examination of the nose and sinuses with CT scanning may help diagnose structural abnormalities and any coexistent sinus infection. Management 1. Medical. Antibiotics may be used to treat any co-existent infective component and a short course of oral steroids is often helpful to get an initial response. However the mainstays of maintenance treatment are as follows: (a) Intranasal steroids. Many cases respond well to topical intranasal steroid preparations although in some the response is disappointing. (b) Antihistamines are useful in some cases. Older preparations such as chlorpheniramine have anticholinergic effects and are to be preferred but sedative side-effects may be troublesome. Topical preparations can sometimes have an impressive local effect. (c) Topical ipratropium bromide is useful for its anticholinergic effect in reducing rhinorrhoea. (d) Systemic sympathomimetics can be helpful (e.g. pseudoephedrine), though they may produce unpleasant side-effects such as dry mouth, constipation and excitability. They should not be used long term or in children. (e) Local nasal decongestants. Self-medication with topical vasoconstrictors (e.g. xylometazoline, ephedrine) is common and initially successful in bringing relief to the patient with enlarged turbinates by reducing blood flow in them. Unfortunately, when the effects wear off, there is a reflex vasodilatation causing increased blood flow and turbinate engorgement (rebound phenomenon). Prolonged use leads to an aggravation of symptoms, which eventually become unre-sponsive to the decongestant, and rhinitis medicamentosa may supervene. The treatment is to stop the decongestant and prescribe topical nasal steroids. (f) Interleukin antagonists. Although not yet established in the management of this condition, it is likely that developments in this area will ultimately prove helpful. Some clinicians are already using them on a limited basis and with some success. 2. Surgical. Surgical treatment is useful for the control of symptoms, particularly nasal obstruction, when medical treatment is ineffective. (a) Treatment of concomitant problems. Associated nasal polyps are treated with excision or topical intranasal steroids as appropriate. Correction of septal deflections and spurs should be considered to relieve an obstructed airway.

Inferior turbinectomy is associated with slightly higher morbidity from postoperative haemorrhage but is more successful for long-term symptom control. cryosurgery and multiple outfractures are all successful in the short term. There is no doubt that any associated sinus disease can be addressed with FESS. 84. p. 174. Most procedures are aimed at reducing the bulk of the inferior turbinate to improve the airway. 1999. p. Vasomotor rhinitis (editorial). Initial enthusiasm for Vidian neurectomy for the relief of rhinorrhoea without nasal obstruction waned when it became apparent that over 50% of patients relapsed within 1 year. Journal of the Royal Army Medical Corps. 11.134 OTOLARYNGOLOGY (b) Turbinate surgery. Submucosal diathermy. but obstruction recurs after 1–2 years. Banfield GK and McCombe AW. Functional endoscopic sinus surgery. 145:18–19. 1996. Some clinicians will also trim the middle turbinates in this procedure to achieve significant improvements in the nasal airway. The theoretical risk of atrophic rhinitis has not materialized in UK practice. (d) Functional Endoscopic Sinus Surgery (FESS). 21:198–202. Further reading Jones AS. Related topics of interest Allergic rhinitis. This operation divides the parasympathetic nerve supply to the nose as the nerve of the pterygoid canal (Vidian nerve) enters the pterygopalatine fossa. 294:1505–1506. British Medical Journal 1987. Idiopathic rhinitis: idiopathic or not? Clinical Otolaryngology. Lancer JM. . p. Partial resection of the middle turbinate at functional endoscopic sinus surgery. p. (c) Vidian neurectomy. linear diathermy. laser cautery. Carney AS and Jones NS. Nasal polyps. Examination of the nose. 108.

Tullio phenomenon The Tullio phenomenon is defined as vertigo in the presence of loud sounds. The mechanism is pressure transmission to the labyrinth causing endolymph movement and stimulation of the labyrinthine sense organs. The phenomenon occurs when sound energy is transmitted from a mobile stapes foot-plate to the labyrinth which is distensible only when there is a fistula. A breach will usually result in a dead ear. suppurative labyrinthitis. this scenario arising in the 1950s in patients with severe adhesive otitis. The phenomenon may also arise in those with endolymphatic hydrops when it is thought to be secondary to sound energy transmission from the footplate to the distended saccule which may be touching the undersurface of the footplate in advanced cases. but not breach. Three important definitions are provided to aid their understanding. A fistula most commonly occurs in the dome of the lateral semicircular canal. The fistula sign In the presence of a labyrinthine fistula. the endosteum of the labyrinth. For example . On occasion it may occur by a similar mechanism to the Tullio phenomenon. Releasing the pressure allows the deviated eyes to return to the midline. Labyrinthine fistula A labyrinthine fistula is a bony erosion of the labyrinthine capsule to expose.LABYRINTHITIS Labyrinthitis is an inflammation of the labyrinth and may be classified into serous labyrinthitis. The fistula may have been present. perilabyrinthitis and paralabyrinthitis. raising the ear canal pressure of the affected side may cause conjugate deviation of the eyes away from the affected ear. but silent. Historically the phenomenon occurred if a fenestration procedure was performed in the presence of a mobile footplate. before surgery. Perilabyrinthitis Perilabyrinthitis is a syndrome caused by a labyrinthine fistula after mastoid surgery in the presence of retained labyrinthine function. This occurs either directly if there is labyrinth endosteum exposed to the ear canal after mastoid surgery or indirectly if endosteum is covered by disease that can transmit the pressure wave such as cholesteatoma.

that is a nystagmus towards the affected ear. If there are no features to suggest a meningitis the important diagnosis not to miss is a cerebellar abscess. As compensation gradually occurs second degree nystagmus develops (nystagmus when gazing straight ahead or looking in the direction of the nystagmus) and then first degree nystagmus (nystagmus only when looking in the direction of the nystagmus). Alternatively the fistula may be iatrogenic. Investigations of labyrinthitis The diagnosis is made on the clinical features occurring in the presence of a precipitating factor. In parallel with these changes is an improvement in mobility and symptoms. Finally there is absence of nystagmus on optic fixation.136 OTOLARYNGOLOGY when secondary to cholesteatoma. In this position the patient will tend to voluntarily look in the direction of the affected side (especially when they have visitors). Here the symptoms and signs are different. Treatment consists of occluding the meatus with cotton wool when outdoors or grafting the fistula with temporalis fascia. Clinical features Labyrinthitis is most commonly virally induced but may be secondary to CSOM. reducing the drive from the unaffected ear so that the corrective nystagmus and therefore the vertigo will be less severe. The ears should always be examined under the microscope and if any debris is found it should be removed. there is an acute onset of violent. overwhelming vertigo that is so severe it inhibits the perception of tinnitus and hearing loss. Vertigo may also arise in perilabyrinthitis on windy days when the relatively cooler wind produces a thermal gradient across the labyrinth and a difference in the specific gravity of endolymph at each end of the semicircular canal to cause circulation of the endolymph within the canal. the nystagmus occurring as a corrective measure. that is nystagmus in any direction of lateral gaze. but soon a paralytic jerk nystagmus to the healthy ear ensues. Initially there is third degree nystagmus. or may also be a complication of ASOM via the round window. Tiny movements of the head exacerbate the vertigo so that the patient prefers to lie completely still on his side and in the presence of a paralytic nystagmus the affected ear will be uppermost. Paralabyrinthitis This is vertigo occurring in the presence of CSOM when inflammation close to the endosteum of the labyrinth causes an irritative nystagmus. Typically. sealing the graft with fibrin glue and a temporalis muscle flap. The symptoms and signs are identical to suppurative labyrinthitis except in the latter the loss of inner ear function is irreversible. Serous and suppurative labyrinthitis Serous labyrinthitis is a retrospective diagnosis and depends on there being some recovery of cochlea and vestibular function after an attack of postulated bacterial labyrinthitis. The hallmarks of perilabyrinthitis are the Tullio phenomenon and a positive fistula sign. A labyrinthine fistula may be visible. There may be a short period of irritative jerk nystagmus towards the affected ear. but may be difficult to recognize . the mass of the cholesteatoma sac prevents distension of the labyrinthine endosteum. This can be understood when we explain the normal labyrinth causes conjugate deviation of the eyes to the opposite side so that if one labyrinth is paralysed the opposite labyrinth will become dominant and deviate the eyes to the side of the affected ear.

Cooksey-Cawthorne exercises may accelerate central compensation. • An ear culture swab if there is evidence of middle ear infection and appropriate antibiotics. exploration of the mastoid after recovery from the acute symptoms. Sequential pure tone audiometry and electronystagmography (ENG) will allow the monitoring of recovery although hearing loss and vestibular failure is permanent with purulent labyrinthitis. Neurotrophic factors and antioxidants may therefore have a significant future role to play in the protection and recovery of inner ear receptors from injury of any aetiology. • Counselling is a necessary but often overlooked part of the management. An enhanced CT or MRI scan will be necessary in these circumstances. . Antioxidants will reduce sensory hair cell loss due to cisplatin and the protective function of antioxidants to gentamicin ototoxicity and to acoustic trauma has also been demonstrated. avoiding head movements. should be considered.LABYRINTHITIS 137 in a patient continuously vomiting. The chronic disease should be eradicated and if a fistula is identified the treatment is described above. • Vestibular sedatives. Cochlea hair cells are more susceptible to injury than vestibular receptors which suggests the latter receptors should respond well to such attempted rescue and further work is on going. Management of labyrinthitis Treatment of both the precipitating factor and the labyrinthitis is necessary. if they develop a severe illness (allows inhibition of central compensation) or if they should develop a neuropathy affecting the peripheral proprioceptors. Osmotic pump infusion and viral vector delivery of GDNF into perilymph has attenuated kanamycin and ethacrynic acid sensory cell loss. Follow up and aftercare • After recovery from the acute infection. Growth factors of particular interest are brain-derived neurotrophic factor (BDNF) and glial cell line-derived neurotrophic factor (GDNF). Furthermore changes in BDNF expression following trauma are correlated with the degree of regeneration. • Bed rest. broad spectrum until results of the swab are available. • Intravenous fluids if vomiting. The BDNF gene. A labyrinthine fistula may have arisen from chronic osteitis or cholesteatoma. • If the precipitating factor was CSOM. Future advances Growth factors and antioxidant cocktails may provide protection to the labyrinth from progressive damage and may allow regeneration of vestibular receptors. Even with complete central compensation patients with unilateral labyrinthine failure will still be unsteady in the dark. using a herpes simplex virus (HSV) vector has been injected into the cochlea of mice whose hair cells had been killed with neomycin which allowed a near total rescue of cells within 4 weeks.

p. et al. Transforming growth factor alpha treatment alters intracellular calcium levels in hair cells and protects them from ototoxic damage in vitro. Rhinology and Laryngology. p. 1997. 102:198–205. 1993. 5. Annals of Otology. p. Chronic suppurative otitis media. . Staecker H. 15:553–562. Vertigo. Related topics of interest Caloric tests.138 OTOLARYNGOLOGY Further reading Shepard NT. Malgrange B. p. Raj A. 346. Int J Dev Neurosci. Dazert S. p. Vestibular and balance rehabilitation therapy. 38. Vestibular function tests. Smith-Wheelock M. 27. Telian SA. Acute suppurative otitis media. 350.

aryepiglottic folds and the epiglottis (laryngeal surface. 3. It is about five times commoner in males than in females. Hoarseness is the commonest and often the only presenting symptom. but persons who smoke tobacco and drink alcohol are predisposed to the disease. Dysphagia indicates invasion of the pharynx. the larynx is divided into three regions which each include a number of sites: 1. but the peak age of presentation is in the seventh decade. Patients with a cancer in this site may complain of a unilateral sore throat. vestibular folds. There should be a general examination to identify distant metastases and an assessment of the overall physical status of the patient. Dyspnoea and stridor are late symptoms and almost invariably indicate an advanced tumour. adenoid cystic carcinoma. Cough and irritation of the throat are occasional symptoms. The incidence increases with age. Glottis. Alcohol on its own is probably not a cause of laryngeal cancer but it is highly synergistic with smoking. It is very rare in non-smokers. Clinical features The clinical features of malignant disease are dictated by the primary tumour. Pain is an uncommon symptom but is most typical in supraglottic tumours. This comprises the larynx superior to the apex of the ventricle. There may be referred otalgia. arytenoids. Verrucous carcinoma is a distinct variant of welldifferentiated squamous cell carcinoma. chondrosarcoma and lymphomas are all rare. In some areas of India and Malaysia it is the most common cancer and is probably related to variations in smoking habit. This extends from the inferior border of the glottis to the lower border of the cricoid cartilage. tip and lingual surface). For classification purposes.LARYNGEAL CARCINOMA Pathology Squamous cell carcinoma of the larynx is the commonest head and neck cancer in the Western world and represents approximately 1% of all malignancies in men. The cause of cancer of the larynx is not known. Indirect laryngoscopy should allow an inspection of the primary tumour site . secondary deposits and the general effects of cancer. The general symptoms of anorexia. respectively. cachexia and fetor imply advanced disease. It extends from the apex of the laryngeal ventricle to 1 cm below. fibrosarcoma. 2. Adenocarcinoma. It includes the ventricle. Supraglottis. Subglottis. Some authorities hold that the superior and inferior borders of the glottis correspond to the superior and inferior arcuate lines. This comprises the vocal cords and the anterior and posterior commissures. Swelling of the neck may be due to direct penetration of the tumour outside the larynx or to lymph node metastases. The symptoms and signs of a laryngeal tumour depend on the way in which it is related to the upper aerodigestive tract.

In addition. There are three areas which are difficult to examine by this technique: the subglottis. mucosa of tongue base). mobility and level of the nodes.140 OTOLARYNGOLOGY and size. and even with this standard there is considerable variability. MRI or CT scans of the larynx and neck provide further information about the primary tumour. clinical staging is the only generally reliable criterion of any prognostic significance. All the larynx sites should be inspected systematically. therefore. An isotope bone scan is indicated only if symptoms suggest bony metastases or there is a raised serum calcium or alkaline phosphatase. The serum analysis may show deranged liver function raising suspicion of liver metastases. Distant metastases are unusual in laryngeal carcinoma at presentation (1–5%). Biopsy material should include an adequate amount of representative tissue to obtain a definitive diagnosis of malignancy. Cord mobility should be assessed as the patient wakes if not done already.g. also undergo fibreoptic laryngoscopy. An accurate anatomical description of tumour extent (with a case file diagram or photograph) is therefore essential in treatment selection. Investigations A chest radiograph. neck or lung is in the region of 1–5%. All patients should. An ultrasound scan of the liver is required if hepatic metastases are suspected and in some units this is routine prior to major surgery. or hypoproteinaemia. identification of the tumour type and tumour differentiation. full blood count and serum analysis are baseline investigations prior to a general anaesthetic. T1 Tumour limited to one subsite of the supraglottis. but supraglottic tumours may cause bilateral nodes. The neck should be carefully palpated for the presence of enlarged lymph nodes. In cancer of the larynx. and some subglottic tumours may spread to the upper mediastinal nodes. the laryngeal surface of the epiglottis and the laryngeal ventricle. Laryngeal tumours usually metastasize to the upper deep cervical lymph nodes. Clinical staging attempts to group together features which may share a level of prognosis or a certain treatment. T2 Invasion of more than one subsite of the supraglottis or glottis or adjacent region outside the supraglottis (e. The incidence of a synchronous second primary tumour in the head. . Direct laryngoscopy under general anaesthesia is mandatory. which may indicate malnourishment and a possibility of poor wound healing. the patient should have a full panendoscopy including bronchoscopy. The tumour’s position and extension should be recorded by means of a diagram in the case notes. While the patient’s neck muscles are relaxed under general anaesthetic the neck should be palpated for nodes which may not have been noted previously. The chest radiograph should be carefully examined to exclude metastases or to assess intercurrent lung disease. Supraglottis. Imaging may also uncover the presence of impalpable or occult nodes. Staging Laryngeal tumours are diverse in their behaviour and prognosis and thus there have been many endeavors to classify them. The information from the investigations of the patient allow the surgeon to ‘stage’ the tumour according to the TNM classification and manage it accordingly. Examination must include an assessment of the number. Vocal cord mobility should also be assessed. A CT scan of the chest may be indicated if suspected lung metastases need further delineation.

Bilateral dissection of levels II-IV with inclusion of level I if tongue base involvement and level VI if subglottic spread. The subglottis drains to paratracheal and mediastinal nodes in addition to the cervical lymph node. The supraglottis has a rich lymphatic drainage. Confined to the larynx with a fixed vocal cord. T4 Extends beyond the larynx. The glottis has virtually no lymphatic drainage. Larger tumours tend to be treated with primary surgery. Vocal cord fixed. Tumour extends to supraglottis and/or subglottis. Management of the neck will depend on nodal status (see Cervical Lymphadenopathy and Neck Dissection chapters). Glottis. N1 disease in cancers from all sites of the larynx can be treated by modified radical neck dissection and N2/N3 by radical neck dissection with a modified dissection on the contralateral side if required. Extends beyond the larynx. general condition. Supraglottic tumours have a high incidence of overt and occult nodal metastases and the NO neck needs elective treatment in these cases. but assessment of lymphadenopathy is subjective. Tracheostomy. although not desirable. and a high proportion of these tumours spread to cervical lymph nodes. or impaired cord mobility. . and a similar number of palpable nodes are not invaded by tumour. Patients who present with stridor should have endoscopic debulking carried out when possible. Some authorities maintain that transglottic tumours arise from the laryngeal ventricle. T1 T2 T3 T4 Tumour limited to subglottis. Involves both vocal cords. Subglottis.LARYNGEAL CARCINOMA 141 T3 Confined to larynx with a fixed vocal cord or invades the postcricoid area. may be necessary. base of tongue. with surgery reserved for recurrence. As a general rule. 1. About one-third of patients with no palpable lymph nodes have histologically invaded nodes. surgery or a combination of these two modalities. Extends beyond the larynx The presence of palpable lymph nodes is the most important factor in determining prognosis. Preservation laryngeal surgery is also an option with small tumours. usually with postoperative radiotherapy. and stage of the tumour: curative treatment or palliative treatment. small tumours are treated by radical radio-therapy in the first instance. Extends to vocal cords with normal or impaired mobility. epiglottic tissues. Management Each patient will fall into one of the following treatment categories depending on their age. so metastases usually only occur when the tumour has spread to involve the supraglottis and subglottis in the so-called transglottic tumour. T1 (a) T1(b) T2 T3 T4 Tumour limited to one vocal cord. Curative treatment may involve radiotherapy.

Radiotherapy has the advantage of leaving the patient with his larynx. Glottic tumours. then every 2 months for 6 months. Endoscopic resection may have a role in selected T1 cases. radiotherapy has been the conventional treatment of choice for T1 glottic tumours. but there is often persistent oedema. T4 Tumours will be treated by total laryngectomy and a radical neck dissection if there are any nodal metastases with post-operative radiotherapy. sometimes as an emergency procedure. Small tumours may be treated by radiotherapy. combined with a neck dissection. Radiotherapy may be better for extensive superficial tumours because of the better functional results obtained. . Larger tumours causing stridor will need a total laryngectomy. Some units continue to monitor patients as the incidence of second primary tumours is in the region of 10–20%. T2 They can be similarly managed by radiotherapy or by partial laryngectomy. Furthermore. insertion of a percutaneous gastrostomy. The results of salvage surgery for recurrences after radiotherapy are poor. then 6 monthly for the next 3 years. All patients should have had modern method of voice restoration following laryngectomy including valved speech. Alternatively. The subglottis becomes involved in extensive glottic and transglottic carcinoma. T3 Many T3 glottic tumours are treated in the first instance by radiotherapy. giving cure rates in excess of 90%. and have their weight recorded in the outpatient clinic on a regular basis. every 3 months for 12 months. chemotherapy and occasionally surgery. approximately 50% of T3 laryngeal carcinomas are understaged and are in fact T4 tumours due to extension through the cricothyroid membrane or from unsuspected cartilage invasion. They will also require monitoring of their thyroid function and calcium levels if there has been a thyroid gland excision. Patients who have had a laryngectomy will require speech therapy. but its use is controversial. Follow-up and aftercare Patients who have had potentially curative treatment should be carefully examined for signs of primary recurrence. Larger tumours will require treatment by either a supraglottic laryngectomy or total laryngectomy. This should be monthly for the first 6 months. sometimes with aspiration and poor function of the larynx. It is important that the upper mediastinum is included in the radical treatment regimen. but vertical partial laryngectomy is sometimes an alternative. T1-T2 T3-T4 Usually treated by radiotherapy or conservation surgery. but these tumours often present late and the patient needs a total laryngectomy. palliative radiotherapy. neck node spread and distant metastases. Early involvement of the palliative care team. Primary surgery with post-operative radiotherapy is therefore recommended for high volume lesions. Palliative treatment includes pain relief. Pure subglottic cancer is very unusual. Subglottic tumours. small tumours confined to one vocal cord can be treated by endoscopic laser resection or open cordectomy.142 OTOLARYNGOLOGY 2. T1 In the UK. tracheostomy. Supraglottic tumours.

. 264. p. 143. British Association of Otolaryngologists. p. 13:399–409. 29.LARYNGEAL CARCINOMA 143 Further reading DeSanto LW. Review. 1993. 2000. Current Opinion in Otolaryngology and Head and Neck Surgery. p. Related topics of interest Cervical lymphadenopathy. Effective Head and Neck Cancer Management. p. Head and Neck Surgeons. Neck dissection. 336. Tracheostomy. Second Consensus Document. Wilson J (ed). 185. Clinical Otolaryngology. Cancer of the larynx. Laryngectomy. Radiotherapy. 1:133–136. 1988. Prognostic factors in laryngeal carcinoma. p. Stell PM.

. (a) Supracricoid partial laryngectomy. Near-total laryngectomy. etc. fibrosarcoma. the main handicap associated with this procedure. 2. The repertoire must include conservation techniques including laser surgery. Vertical partial resection. are popular in the USA and Continental Europe. The goals of conservative laryngeal surgery are to control cancer and obtain a functional outcome of speech and swallowing without the need for a permanent tracheostomy. according to quality of life studies. (b) Supraglottic laryngectomy. Types of laryngectomy 1. Although patients may undergo speech rehabilitation and may swallow well after removal of the larynx. the general health of the patient and the relative consequences of the treatment. In general in the UK. appears to be the need for a permanent stoma.LARYNGECTOMY The choice between surgery and radiotherapy as treatment for carcinoma of the larynx should be made according to the likely effective control of the cancer. With both a laryngectomy and radiotherapy there is invariably some or total loss of normal voice and compromise of airway protection and function. radiotherapy is reserved for smaller tumours (T1 and T2). chondrosarcoma. verrucous carcinoma. (b) Hemilaryngectomy (frontal. (a) Epiglottectomy. lateral and fronto-lateral). whereas surgery is considered more effective for larger tumours (T3 and T4) and when there are secondary deposits of carcinoma in the lymph nodes of the neck. Radiotherapy has the advantage of vastly reduced morbidity compared with surgery. It is apparent that the modern surgeon should not manage laryngeal cancer on the basis of one surgical option (total laryngectomy). Conservative approaches which attempt to preserve as much of the larynx and its function as possible. partial laryngectomy and surgical voice restoration. 3.) are invariably treated by laryngectomy. Horizontal partial resection. (a) Cordectomy. The other less common malignant neoplasms of the larynx (adenocarcinoma.

Total laryngectomy. A CT or MRI scan of the larynx should be obtained. Consent for total laryngectomy should always be obtained before embarking on any partial resection. It should be remembered that this situation will be distressing for the patient. It involves removal of half of the thyroid cartilage. if on histological . Specifically for a laryngectomy the patient must be warned that the voice box will be lost and a new technique to speak will need to be learned. liver function tests and a full blood count will be required. However. Written confirmation of the histological diagnosis must be in the case notes or the surgeon should have personally spoken to a senior pathologist to confirm the diagnosis of cancer when a frozen section result is presented. The operation should be described and the patient should have knowledge of the wounds. The patient should be cross-matched for 2 units if a total laryngectomy is proposed. nasogastric tube and sutures. the tumour to be staged and the appropriate operation planned. with the false and true vocal cords. However. The explanation and warnings should be logged in the case notes. with an adequate margin of healthy tissue. Investigations A panendoscopy should always be performed by the surgeon prior to operation. part of the supraglottis and the upper half of the cricoid cartilage. This will allow a representative biopsy to be obtained. drains. The resulting gap is closed by the strap muscles. Patient preparation The patient should have a clear explanation of the diagnosis and what it means. A chest radio-graph and liver ultrasound scan are essential (in addition many authorities would advocate a chest CT scan). 4. The patient should be warned before any treatment that there is no guarantee of cure. The speech therapist should see the patient preoperatively. Serum urea and electrolytes. etc. Excision can be performed using the KTP or CO2 laser. It is performed much less frequently in the UK owing to the equally effective results achieved by radiation. This procedure therefore has the advantage of allowing some protection for the airway and a reasonable voice for the patient. Hemilaryngectomy This technique can be used to remove tumours confined to the vocal cord. The patient should be investigated to allow surgery to proceed and to exclude distant metastases. Cordectomy This is indicated for a T1-T2 cancer of the glottis which does not reach the anterior commissure or the arytenoid cartilage. It can be performed by an endoscopic or open approach. a permanent end tracheostome will be necessary. new perspectives will continue to challenge old ones and the current trend is for endocopic laser resection to be offered to patients more often. and thyroid and parathyroid supplements may be needed for life following the operation.LARYNGECTOMY 145 (b) Vertical subtotal laryngectomy. fashioned so as to form a new fixed vocal cord. Cordectomy also remains a suitable operation for the removal of benign laryngeal tumours. who should have a relative or close friend present.

The aim of these two procedures is excision of tumour and to allow speech and swallowing without a permanent tracheostomy. The procedure that is used for selected supraglottic and transglottic carcinomas results in a more extensive resection. It is also indicated as salvage surgery in failed radiotherapy. The technique involves removing the entire supraglottis from the vallecula to the ventricle. The operation is not suitable if the tumour extends to the base of tongue or vocal cords. thyroid and cricoid cartilages and several rings of the proximal trachea and an ipsilateral thyroid lobectomy or total thyroidectomy. Xth and XI th cranial nerves. hence the name crico-hyoid-epiglottopexy. after laryngoscopy and . the procedure is called cricohyoidopexy. Total laryngectomy Total laryngectomy is indicated for the curative treatment of laryngeal carcinoma when the tumour is considered to be unsuitable for either radiotherapy or a partial resection. and joining the lower half of the larynx to the base of the tongue. In this case closure is performed by pexy between the cricoid and the hyoid and tongue base. All patients having a total laryngectomy should have a speech valve inserted at the time of the operation. with removal of the entire epiglottis and pre-epiglottic space. The technique involves removing the hyoid bone. therefore. within 24 hours of presentation. and a maximum of one arytenoid cartilage are resected. as a palliative measure in some advanced cases of carcinoma and as a last resort in those who have no voice and chronic aspiration due to palsy of the IXth. if the patient is over the age of 65 years or if there is intercurrent lung disease. The laser can be used to debulk the tumour and improve the airway. Supraglottic laryngectomy This is indicated for cancer of the supraglottis (epiglottis and laryngeal vestibule). Emergency laryngectomy An emergency laryngectomy is a laryngectomy performed on a patient with airway compromise due to carcinoma. the whole thyroid cartilage. the hyoid and the remaining epiglottis and tongue base. without a prior tracheostomy. If the operation is to be carried out for post-radiotherapy recurrence.146 OTOLARYNGOLOGY examination there has been incomplete resection of the lesion. The main disadvantages of this procedure are that the patient’s normal voice is lost and a permanent end tracheostome is required. Cricopharyngeal myotomy is considered an essential manoeuvre to make swallowing easier. the supracricoid partial laryngectomy (SCPL) falls between the vertical partial laryngectomy and the supraglottic laryngectomy at one extreme and total laryngectomy at the other. It should be preceded by direct laryngoscopy to assess the extent of disease and likelihood of successful resection. Supracricoid partial laryngectomy In the spectrum of procedures available for the surgical management of laryngeal carcinoma. The procedure should be avoided by proper planning and if possible by establishing an airway when such patients present. There are actually two groups of SCPLs. either postoperative radiotherapy or total laryngectomy should be performed. it is important that the extent of the original lesion is known. Closure is between the cricoid. The first is used for selected glottic carcinomas in which both true and false cords.

Tumours of the larynx. 311. Tracheostomy. Olofsson J. Performing a tracheostomy for the relief of airway obstruction due to carcinoma prior to any definitive treatment is associated with a high rate of stomal recurrence. Cook JA. 138.LARYNGECTOMY 147 biopsy. 17:433–436. Treatment of T3 carcinoma of the larynx by surgery or radiotherapy. A number of solutions have been offered to this problem. 2000. Journal of Laryngology and Otology. Robin PE. Clinical Otolaryngology. Further reading Gibson A. p. . 336. In: Scott-Brown’s Otolaryngology. 6th edn. Wilson J (ed). Second Consensus. Soler Lluch E. 113:349–352. Phillips D. Chaper 11. Thyroid function and calcium levels should be checked appropriately. London: Butterworths. to inadequate resection or to a second primary. p. the patient counselled and further treatment planned. McCombe AW. 147. British Association of Otolaryngologists. 5. Head and Neck Surgeons. 1992. 1997. Effective Head and Neck Cancer Management. Related topics of interest Laryngeal carcinoma. The psychological consequences of laryngectomy. Follow-up and aftercare Voice rehabilitation and periodic surveillance for recurrence or second tumour are the main features of follow-up. p. Some groups have argued that if definitive treatment is undertaken within 48 hours of the tracheostomy the rate of stomal recurrence is not increased. The rationale for emergency laryngectomy is based on the dismal prognosis for any patient who develops a tumour recurrence in their tracheostome: so-called stomal recurrence. Jones AS. Stridor and stertor. This has the advantage of avoiding any surgical disturbance of the regional anatomy. 1999. Lasers in ENT. yet secures the airway while the biopsy results are awaited. p. Vol. This could be due to tumour seeding at the time of tracheostomy.

An optical resonating chamber has a fully reflective mirror at one end and a partially reflective. In 1955 microwaves were produced in this fashion and in 1960 the first laser was built by Dr T. and so its tissue effects. partially transmitting mirror at the other. This light is monochromatic (same colour). thereby releasing a photon of energy. collimated (parallel and unidirectional) and coherent (intense and in phase) and therefore represents an extremely powerful. Historical The theoretical foundations for lasers were postulated by Einstein in 1917. he proposed that electromagnetic radiation (including light) could be produced by an electron of an atom jumping from a high-energy atomic shell to a lower energy shell. Should this photon strike an atom or molecule identical to that which released the photon and which is in a high-energy state. Total energy delivery to the tissues is dependent on the power density of the beam and the duration of exposure. The electron must first be stimulated into the higher energy shell by an external energy source. high-energy beam. This laser burn is extremely accurate. travelling in the same direction as that which stimulated the emission. As this whole process results in the production of heat. and will cause tissue damage which varies with its penetration. This results in emitted photons. It can be controlled by three methods. which bounce around the inside of the chamber. Technical background All currently available medical laser devices work in a similar fashion. The total power of the beam (watts) is set at the laser control panel. Through this chamber is pumped the laser medium. In essence. the electron which released the photon dropping to a lower energy level. the optical chamber is surrounded by a water-jacket cooling system.LASERS IN ENT Laser is an acronym for light amplification by the stimulated emission of radiation. only those parallel to the long axis of the resonating chamber are able to escape through the partially transmitting mirror as laser light. Tissue effects The wavelength of light produced. The . It may then be passed through a lens system for focusing. depend on the laser medium used. Maiman using synthetic ruby crystals. another photon will be released. which is stimulated by an electrical current. The wavelength of the photon would depend on the energy difference between the two energy shells and so would be identical for all atoms of a specific element or molecule. All the effects of lasers are due to the local absorption of energy and the subsequent production of heat in the tissues. usually electrical.

but its disadvantage is that its poor penetration will certainly not coagulate blood vessels more than 0. a bloodless field will only be gained with a more penetrative laser. Consequently it is invisible to the human eye and the system is usually provided with a low-power helium-neon laser carried coaxially to act as a sighting beam. Diode lasers. Thus it vapourizes narrower.3 mm penetration). Exposure time (seconds) can also be set at the control panel in pulsed mode or left as continuous mode. It can be used in contact mode with a sculptured quartz or sapphire tip. The holmium:YAG (Ho:YAG) laser. such as the tongue. Pulsing reduces the exposure time. Energy from the argon laser is particularly well absorbed by pigmented tissues. regardless of pigmentation. . The Nd-YAG laser is prone to light scattering and so tissue effects may be evident 2–4 mm from the target site. The carbon dioxide laser produces light in the far-infrared range (wavelength 10 600 nm). such as the retina of the eye. silktouch system). To date they are being manufactured to offer wavelengths in the region of 630–1000 nm. the KTP being ideal. The KTP laser is a modification of the Nd-YAG laser. It is therefore less precise than the other lasers but will coagulate vessels 1. For skin surgery in order to achieve correct energy densities. The Er:YAG has a water absorption coefficient 10 times that of these systems. When excising lesions in tissue with larger vessels. 2. It main use has been in laser skin resurfacing. These are becoming increasingly available. produces light of wavelength 1064 in the near-infrared range.g. 6. this can vapourize bone with little collateral damage.5–2 mm in diameter. The Nd-YAG is mostly used in fibreoptic bronchoscopy and oesophagoscopy. The argon laser produces visible blue/green light with light at a number of wavelengths. Its effect then is that of a hot knife cleaving tissue bloodlessly without deeper effects. Types 1. notably haemoglobin. and its effects are extremely localized (0. The energy of the CO2 laser is strongly absorbed by any watercontaining tissues. but mostly 488–514 nm. but those with shorter wavelengths tend to be much less powerful. with a concomitant increase in the power delivered in that time. This property has made the Ho:YAG laser a candidate for use in sinus surgery which necessitates the removal of bone. may gradually take over this work. 3. which is advantageous in areas where small haemorrhages will prove disastrous. 4. and so is also invisible. in which a crystal of potassium titanyl phosphate is stimulated by a krypton arc lamp. 5. The erbium YAG (Er:YAG) laser. The Nd-YAG laser has a crystal of neodymium doped-yttrium aluminium garnet stimulated by a krypton arc lamp. They may be used with optical fibres and have properties similar to those of the Nd-YAG laser with respect to coagulating tissue in non-contact mode and as a ‘hot knife’ in contact mode. Techniques exist for further shortening of the pulse (ultrapulse and Q-switching). the CO2 laser needs to be pulsed (e. These are important for the confinement of the thermal energy.g. With a wavelength of 2100 nm.LASERS IN ENT 149 area of the spot is altered by adjusting the focus of the beam.5 mm in diameter. ultrapulse system) or flash scanned (e. to produce a beam of 532 nm visible green light. thinner segments of tissue and has more control of the zone of thermal necrosis. The advantage of this is that it can accurately destroy small volumes of tissue with minimal surrounding tissue injury. 7. by being more precise. which causes a sudden increase in volume and vaporization. Tissue penetration is about 1 mm and so it will accurately and reliably coagulate vessels of this diameter. although the KTP laser. It kills cells by boiling the water content of cells (80% water).

Personnel. The argon laser can be used in stapedectomy to divide the crura and fashion a stapedotomy. Nose. The Ho:YAG has been advocated for use in sinus surgery as it is powerful enough to ablate bone. It has been suggested that a defocused beam be used to reduce the incidence of residual cholesteatoma in mastoid surgery. The CO2. Ear. so there is less chance of post-operative airway compromise. minimizing cochlea trauma. Obstructing laryngeal and tracheobronchial tumours may be debulked with this or the KTP laser. Recent studies have shown that cordectomy for T1 vocal cord squamous cell carcinoma provides a similar prognosis to radiotherapy regarding tumour recurrence. Treatment with this laser results in minimal injury to surrounding tissue and minimal postoperative oedema. 1. in the symptomatic treatment of rhinitis. These include papillomata. the KTP laser will be less likely to cause troublesome bleeding in these instances and will vaporize tissue more efficiently. The KTP laser has been used (as a weightless knife) for work around the ossicles. However. Throat. A number of protective measures are required and include: 1. Sometimes the laser is not proven to be of greater efficacy than conventional techniques. There is a potential explosion risk with volatile anaesthetic agents and oxygen. Environment The operating theatre should be designated a laser area and appropriate warning signs displayed. 3. It is important to remember that just because a procedure can be done with a laser. 3. with some success. metal tubes. and on occasion small tumours have . It can be used to perform an arytenoidectomy and cordectomy in airway compromise due to vocal cord palsy. polyps. The benefit is. This laser has been used. This may change with the evolution of image-guided surgery. 4. coated tubes and even jet venturi are used. it does not mean that it should be done with a laser. tissue splatters and coats the endoscope lens and charring of the tissues obscures the operative field.150 OTOLARYNGOLOGY Safety Medical lasers are class 4 and their use requires extreme caution. Patient All exposed parts of the patient adjacent to the operating area are covered with damp swabs to prevent any burns. The CO2 laser has found most application in ENT in the treatment of laryngeal conditions. Anaesthetic. to perform endoscopic dacrocystorhinostomy under local anaesthetic. nodules and the division of webs. 2. as well as removing a variety of localized benign intranasal mucosal lesions. To protect the endotracheal tube. relatively short lived. The CO2 laser has been used to perform linear cautery to the inferior turbinates and turbinectomy. Access should be limited to essential personnel only and there should be nominated laser users who are fully conversant with the operation and risks of the laser. Clinical uses A greater range of conditions are now being treated with a variety of lasers. argon and Ho:YAG laser have all been described as being of benefit in the management of hereditary telangiectasia. It has also been used to spot weld tympanoplasty grafts in place. Scar tissue formation is also minimized and so the CO2 laser is the method of choice in the excision of benign lesions from the vocal cord. Current research is evaluating the use of lasers for atrophic tympanic membranes and out-patient myringotomies. These disadvantages have reduced the popularity of the use of lasers in this instance. which may be vaporized at a high power setting. However. All theatre personnel are required to wear eye protection. 2. It provides at least as good voice preservation after healing. It should be equipped with remote door-locks to prevent non-essential personnel straying into theatre during laser use. Carefully controlled trials are needed to confirm these preliminary findings. however.

the KTP laser is the method of choice as bleeding is minimal because of its better penetration. Steiner W. 1999. 138. which is stimulated to release singlet oxygen atoms. Cutaneous telangiectasia and port wine stains or flat macular lesions can be reduced by a flashlamp pulsed dye laser and need several treatments. Prescott C. 223. ENT News. 8(4): 10–24. Vocal cord palsy. This technique has not found a significant application in ENT although its potential for treating laryngeal cancers and papillomatosis has been investigated. p.LASERS IN ENT 151 been completely excised. p. p. A photosensitive haematoporphyrin derivative which shows preferential uptake by the tumour is administered to the patient. A review of lasers in otolaryngology. Although the CO2 laser may be used for excising lesions of the tongue and oral cavity. . p. Laryngectomy. Otosclerosis. This technique has found its greatest use in the treatment of skin cancers. Photodynamic therapy. 354. These are extremely cytotoxic and result in tumour necrosis. A gold vapour laser emitting a red light is used to activate the photosensitizer. Robinson JM. 4. Thick cutaneous haemangiomas do not do well with laser treatment. Ultrapulsed CO2 and Er:YAG lasers are used for resurfacing facial scars and wrinkles. Further reading Carruth J. Jones N. Facial skin. Dilkes MG. 5. Related topics of interest Laryngeal carcinoma. Rhinophyma has been treated with the CO2 laser and is cited as causing less intra and post-operative bleeding when compared to scalpel or electrocautery. 143.

even in the highest ranked journals. many reviewers.Browning Reading the literature is something that most medical post-graduates spend a considerable amount of time doing. the research is so poorly designed or executed that the findings are likely to be so grossly biased as to make them invalid. if it attempts to add to knowledge. we subscribe to it or it is in the library and we feel it has to be read to keep ‘up-todate’. Table 1. unfortunately most of it being poorly directed. though it does not remove the need to be critical of articles. Unfortunately. Peer review This is the process of reviewers critically evaluating an article that is submitted to a journal for consideration for publication. often chosen for their prominence in a specialty. the problem is that the majority of what is written. The reviewers advise the editor on the scientific merit and suitability of the paper for publication. repeats what is already known. Journals relevant to otolaryngology ranked by the quality of their peer-reviewer process . Table 1 is a list of journals most frequently read by otolaryngologists.LITERATURE EVALUATION G. perhaps because it is free. This is mainly because a journal is readily to hand. Or. Whilst this objective is highly desirable. are unable nor have the time to do this properly. which are informally ranked by the quality of their peer review process. Using this should make one focus attention on articles from some journals more than others.

the easier the process becomes. nor reviews. Abstract This will be scanned to ascertain. it does not apply to meta-analyses. Table 2. . the question being addressed. The more knowledge a reader has on scientific methods and the topic being written about. Cochrane). if the question posed had been ‘To assess the efficacy…in comparison to the natural history’ or ‘…in comparison to sac surgery’ the reader would move on to their next question. In addition. rather than the literature itself where the introduction in papers are often biased reviews of the existing literature. alongside the title of the article. most of which will not be read further than the title or the abstract. It does not cover editorials. most would answer ‘Yes’. which are a compilation of papers on the same topic in an attempt to improve the power of the analysis. Example of a structured abstract The reviewers should then ask themselves whether it is a question that would enhance their knowledge or be of practical value to them. On the other hand. we know that there are multiple papers on the topic. even though not the readers’ specialty. This task will be made easier if the abstract is ‘structured’ in its format (Table 2) and an objective clearly stated.g. most of which are biased selections of the literature rather than ‘structured reviews’ for which there is a formal process (e. read no further. which are non-reviewed personal opinions. can increase the former. In the example in Table 2. Reading articles in the top (Table 1) journals.LITERATURE EVALUATION 153 This topic takes a systematic approach to evaluating an article. The next question is ‘What is already known about the topic?’ In this case. Reading a good text book should provide knowledge of what is already known. to which this one does not appear to add anything. In this case.

154 OTOLARYNGOLOGY Study designs What is the ideal study design to answer the question posed? For studies that assess the efficacy of management. there is a well-established hierarchy of levels of evidence Table 3. For continuous outcomes (e.g. Levels of evidence in studies which assess methods of diagnosis of a disease or condition Data which should be presented: Clear definition of characterization of subjects being studied. disease/no disease on X ray).g. Levels of evidence in studies of management Table 4. state sensitivity/specificity/ predictive value of diagnostic algorithms versus accepted gold standard. For dichotomous outcomes (e. results of a laboratory .

How similar is the population being studied to the patients the reader deals with? Patients treated in tertiary centres are at the extreme range of the spectrum. Exclusion bias. One of the reasons why people do not respond could be that they are dissatisfied or at the extreme end of the range of subjects studied (e. (v) odds ratios of significant risk factors with 95% confidence intervals. A sample of 100 ENT surgeons produces the following table: The paper should have read ‘between 40 and 89% of otolaryngologists always discuss facial nerve damage with a patient…’. To help detect these a list of things to look for are given. . Having identified potential bias. (iii) univariate analysis of risk factors with P-values. What the reader ought to do is to pose the question ‘What if the non-responders had all replied in a particular way. 1. This also can occur in prospective studies. In retrospective studies. which is the level of evidence for all current papers on this particular topic. a decision has to be made as to whether it is so gross that the results of the paper are invalid or whether they should be taken with a degree of caution. Response bias. Bias Very few papers are unbiased to some extent. ‘Receiver-operating characteristics’ (ROC) curve showing test per formance over a range of cut-off values.LITERATURE EVALUATION 155 investigation such as audiology). 2. most often unintentional rather than in an attempt to mislead. The most difficult examples of bias to detect are where there is a lack of information. (vi) proportion of population to whom risk factors apply with probability of disease occurrence. (iv) multivariates analysis of risk factor with P-values. The abstract Table 2 suggests a paper at level III. (Table3). This most often occurs with postal questionnaires where less than 85% of individuals respond. Look for a description of those excluded. 3.g. (ii) clear definition of category of controls being reported. What is being looked for is the highest level available. unhappy about the results of treatment). Levels of evidence in studies which investigated the aetiology or epidemiology of a condition Data which should be presented: (i) clear definition of category of subjects being reported. patients can be excluded in a biased manner if they do not fit. Table 5. because they need treatment. would the range of outcomes be?’ Using the following example: ‘89% of otolaryngologists always discuss facial nerve damage with a patient prior to mastoid surgery’ based on a 45% response rate. Population sample bias. Papers on diagnostic tests and on aetiology/epidemiology have different criterion (Tables 4 and 5).

g. 8. Analysis bias. Blinding is necessary whenever the outcomes can be biased by knowledge of what happened to the patient. ‘Generic’ questionnaires cannot be used in all conditions. Randomisation by an independent party is the ideal method. e. Thus a generic Quality of Life Questionnaire for cancer patients is quite inappropriate to use for hearing-aid patients. those allocating treatment should not in any way be able to decide on what the patient gets. The take-rate of myringoplasty 1 week after surgery is irrelevant. Designing questionnaires to assess subjective out-comes is a complicated science and is frequently done incorrectly if at all. Following is an example of a trial of surgery versus medical management for coronary heart disease with death as the main outcome. Control bias. . 6. nor to decide that once allocated the treatment is inappropriate and exclude the patient. to quality of life questions rather than death or an audiogram. Switching between randomization arms is most likely to apply to those allocated to medical management and surgical management. In randomized controlled trials the results should be quoted on an ‘intention to treat’ basis rather than what the patient actually received. If controls are not identical.156 OTOLARYNGOLOGY 4. Here the reader must ask whether the timing of the outcome is an applicable one. it is not the main question being addressed. proven to be relevant in this disease and not covered by a ‘Are you better?’ type question. that is ‘What is the outcome of management strategy A versus strategy B. Bias in timing of outcome. hence objective outcomes are important when this is being assessed. Example of how analysis on an intention to treat basis produces different results from on an ‘abstracted’ basis in a randomized controlled trial. In randomized controlled trials. Blinding of the individual recording the outcome is usually possible but not of the patient if surgery is being compared with a no surgery aim. Non-blinding bias. whether the bacteria are eradicated or the X ray has improved are irrelevant outcomes. The means of assessment to ascribe validity are complicated. 5. Bias in choice of outcome. Thus in papers on chronic rhinosinusitus. it must be at least 6–12 months later. Before reading a paper. Do not be misled by statements such as ‘a validated questionnaire was used’. the reader should think of the outcomes that they would consider important and then to look to see if the ones chosen satisfy that requirement. The temptation here is to compare those actually treated surgically with those treated medically. 7. It is the patient’s symptoms that matter. Randomization bias. consider what magnitude the ‘effect modifier’ might have on the results. knowing that some will change arms during the study?’ (which reflects real life). These factors are called ‘effect modifiers’. This particularly applies to subjective rather than objective outcomes. 9. but the easiest question to ask is whether a specific questionnaire is appropriate to use in the population being studied. Think of what factors affect the outcomes and see if they have been controlled for. These should be assessed in detail by questions. Controls should be identical to the study population in every-thing but the condition being studied. The placebo effect of surgery is large. This will help exclude papers that describe unimportant outcomes. Whilst this is of interest.

1=better. with standard deviations and confidence intervals whilst the latter cannot. and the question being addressed is what should the initial management strategy be. let us assume that there is a strong link between lower socio-economic group and otitis media with effusion (OME). particularly if it fits in with preconceived ideas. Tables are available which can be consulted to see whether this is the case. Type II errors are where no statistical significance was found in a study. the results are the same.e. 11. Thus. If the 95% confidence interval (CI) of the differences between surgical and medical management are looked at. and taking the statistical rule that if they straddle zero (0) the result is not significant. i.g. 10. when a statistically insignificant or negative result is being reported. when analysed on an ‘as treated’ basis. Different statistical methods are required for ‘parametric’ (i. but in many instances too few a number of subjects is obvious.e. The latter is the result to take because in real life patients initially allocated to surgery or medical management will switch. P-values should be interpreted with caution. from which the percentage mortality on an ‘intention to treat’ basis and an ‘as treated’ basis can be calculated. look at the number of patients studied. but not when analysed on an ‘intention to treat’ basis. The former can be reported as means. As an example. there is a lack of power. Papers that looked at maternal smoking as a single factor would have a positive relationship because smoking is . 2=a lot better). A P-value of 0. Of the 394 patients randomized to surgical management. The data shows the number of patients that died. 50 subsequently switched to surgery. The majority of statistical errors are relatively easy to spot. Statistical bias.05 one outcome will be significant as a matter of chance. Take 20 different outcomes and with a P-value of 0. Many papers on aetiological factors fall into the trap of inappropriately linking cause and effect. but this could be due to insufficient numbers of subjects being studied to show this. Interpretation bias. there are significantly fewer deaths in the surgical arm. numerical results with an equal spacing such as height) and ‘nonparametric’ results which may be numerical but not of an equal spacing (e.05 means that there is a 5% chance that the association is not statistically significant. In this particular study it does not matter. 26 did not undergo surgery for various practical reasons. 0=no change.LITERATURE EVALUATION 157 % Death rates Of the 373 patients randomized to medical management.

The evidence based medicine workbook. 1997. Little Brown and Company. 31 people needed to be treated to avoid one death. Churchill Livingston. Clinical epidemiology.158 OTOLARYNGOLOGY common in the lower socio-economic groups. 1997. British Medical Journal Publishing Group. Sackett DL. Such biases are usually unintentional. Others can be intentional. How to read a paper. Such papers could say that this is evidence for mothers to stop smoking to prevent their children getting OME. To do this with colleagues in a group or at a course immensely increases their educational value. Following is an example of the results of a study where death rates between two management arms are being compared: • • • • Reduces rate of deaths by 20%. How to practice and teach EBM. if a study were to look for it. Munro JF. based on the data in the third line. Greenhalgh T. 1991. Evidence-based medicine. Each one is valid but gives a different impression of the difference between the two management strategies. Sackett DL. Such misinterpretations would be less likely if a multifactorial analysis were performed on a full range of factors. . based on a lack of understanding of scientific methodology. The basics of evidence based medicine. Butterworth Heinemann. but nobody would suggest giving cars to those that don’t have them to prevent children getting OME. Critical appraisal for clinical problem solving. et al. your critical skills should be honed and regularly used. Finally. Produces an absolute reduction in deaths of 3%. On the other hand. et al. A basic science for clinical medicine. 1997. Increases survival from 84% to 87%. having read this topic. there would also be a positive association of having OME with non-ownership of a car. Further reading Dixon RA. 2nd edition. Four different methods of describing the difference are shown. et al.

if indicated. . tegmen and sigmoid sinus even in well-aerated mastoids. A myringoplasty is performed at the same time. A properly performed endaural incision will allow good access to the attic. It will not allow sufficient posterior access for a subtotal petrosectomy. Procedure A postaural incision is made at least 1 cm behind the skin fold down to the periosteum. Incisions Either an endaural or postaural incision is used. The disease is usually infective but may occasionally be neoplastic. Neither will the endaural incision allow an adequate angle of approach to the middle ear in those who perform a posterior tympanotomy (required for combined approach tympanoplasty and to access the round window in cochlear implants). Occasionally a cortical mastoidectomy is performed for severe glue ear. A cortical mastoidectomy can also be used as treatment for chronic suppurative otitis media when there is no cholesteatoma. this degree of bone removal is routinely performed by some if there is mastoid disease to allow the postauricular soft tissues to fall into the smooth defect. obviating the need for an obliteration procedure. It provides better access to the sinus tympani and is ideally suited for a small cavity mastoidectomy. leaving cortical bone over the sigmoid sinus and middle fossa dura. The pos-terior canal wall is left intact and the middle-ear contents are not disturbed. for example endolymphatic sac surgery or insertion of a cochlear implant. which is elevated to expose the whole of the mastoid.J.H. Both are equally popular in the UK.Lesser Mastoidectomy is an operation undertaken on the mastoid air cells to remove disease.MASTOIDECTOMY T. A high-speed drill is used to remove the outer cortex of the mastoid bone and then all air cells. It may also be performed as part of a procedure for access to deeper structures. If cholesteatoma is found. including the tip. to clear granulation tissue from the mastoid air cells and the antrum. Cortical mastoidectomy This is also known as the Schwartze operation and is used for the treatment of the acute noncholesteatomatous mastoiditis when medical treatment has failed or complications have set in. the posterior canal wall may be removed and the procedure converted to a modified radical mastoidectomy.

the hearing reconstruction is best left to a second stage. the zygomatic root. This type III can be encouraged if the posterior annulus is medialized when lowering the facial ridge so that the head of the stapes is relatively more prominent. the cavity edges must be well saucerized. When followed backwards. Some cases require an atticotomy only. the retrosigmoid. the malleus and incus are removed. hydroxyapatite. a deep middle ear is helpful and this should be encouraged at the first stage by leaving a lateral annulus. This gives a 5–25 dB conductive loss but profers long-term stability. There are a large number of modifications in the way this operation is performed.g. exteriorizing both into a common cavity. The basic reconstruction involves including the Eustachian tube opening in a reconstructed middle ear using a fascial graft. The bony work on the cavity itself is of greater importance than the obliteration substance. or free muscle. the attic is removed first. If the stapes superstructure is not present. usually temporalis fascia. These procedures will improve the chance of a dry ear and are especially useful in revision surgery. At the second stage a piece of bone or an artificial total ossicular chain prosthesis is placed between drum and footplate. The graft. closure of the external auditory meatus and filling the cavity with free abdominal fat graft in particularly difficult ears. All air cells should be removed. but has to be considered at the same time as the primary surgery even if the tympanoplasty is done as a second stage. Disease-free remnants of the tympanic membrane and ossicular chain are preserved. artificial substances. This appears to encourage squamous epithelium to cover the cavity and it may allow air from the Eustachian tube to fill deep to it and effectively reform a soft posterior canal wall and a near-normal ear canal. and all perilabyrinthine cells. It is also useful if an edge of bone is formed for the new tympanic membrane to take off from. the perifacial.160 OTOLARYNGOLOGY Modified radical mastoidectomy The routine procedure for cholesteatoma is a modified radical mastoidectomy. Procedure In a modified radical mastoidectomy the disease is either approached from behind or followed back from the attic. the middle ear explored and then the antrum opened and the bone removed only as far back as the disease. This is an operation to remove all middle-ear and mastoid disease. The cavity can also be obliterated with bone dust. the operation is called a subtotal petrosectomy. is placed under the drum remnant and often over the whole of the mastoid cavity. the procedure is termed a ‘radical mastoidectomy’. Hearing reconstruction The reconstruction of hearing is dealt with elsewhere. This has the advantage that the cavity is only as big as the extent of disease. There are even more variations in the way the reconstruction is done to minimize the chances of chronic or repeated discharge and maximize the hearing. If a second stage is performed. a cortical mastoidectomy is performed and the bridge of the posterior canal wall drilled away to continue removal of the disease from the antrum. attic and middle ear (atticoantrostomy). When approached from behind. in particular those in Trautman’s triangle. This may be combined with Eustachian tube obliteration. Most British surgeons prefer to accept a type III tympanoplasty with the new eardrum in direct contact with the head of the stapes if it is present. . e. muscle flaps. When all the cells of the mastoid are removed. If all the tympanic membrane. for instance some surgeons try to remove the canal wall in one piece and then replace it at the end of the procedure. the facial ridge lowered to the level of the inferior canal wall and a wide meatoplasty fashioned. Many patients opt for no further surgery or a hearing aid if given the choice. the mastoid tip removed as far medially as the digastric ridge.

It has a high rate of recurrent cholesteatoma. 35.MASTOIDECTOMY 161 Combined approach tympanoplasty This operation removes disease from the mastoid and middle ear. Chronic suppurative otitis media. Related topics of interest Cholesteatoma.and third-look surgery. 38. p. Indeed it may be better to leave disease in situ on such occasions. as is the otic capsule. Complications of mastoidectomy Injury to the anatomical structures of the temporal bone is the main danger for the patient. The combined approach tympanoplasty is the main canal wall up procedure. the risk of deterioration in hearing. the possibility of a dead ear and a chance of postoperative vertigo. 341. Prior to mastoid surgery each patient should be warned about the risk to the VIIth cranial nerve. p. This allows access to disease via the ear canal as well as via the mastoid. The middle-ear part of a mastoidectomy needs equal care to avoid damage to undiseased ossicles. London: Butterworths. A cortical mastoidectomy is extended to remove bone posteriorly over the lateral sinus to allow an adequate angle to visualize the middle-ear contents via a posterior tympanotomy in which the posterior part of the middle ear is entered lateral to the mastoid segment of the facial nerve in the angle between it and the chorda tympani. In: Ballantyne JC and Morrison A (eds). but if performed skillfully it is suitable for patients who are available for long-term follow-up and second. Tympanoplasty. . 1986. It is important to document this discussion in the case notes. The dura and lateral sinus are also at risk. The facial nerve is always at risk and damage to it is the most obvious disaster that can occur. Rob and Smith’s Operative Surgery. p. Further reading Ear. Great care is necessary when removing disease from the lateral semicircular canal as a fistula can be opened and the resulting loss of perilymph may lead to a dead ear.

The main areas covered are: • confidentiality. It states ‘I will respect the secrets which are confided in me.F. A patient may enforce confidentiality through a court injunction and an action for damages in a civil . it is naïve for any medical practitioner not to have a thorough knowledge of the law and how it is applied. for example overhearing a conversation in a lift or at a reception desk.Ramadan and N. • malpractice • negligence • litigation in ENT surgery • complaints against doctors.Roland ‘The regimen I adopt shall be for the benefit of the patients according to my ability and judgement. However.MEDICOLEGAL ISSUES IN ENT SURGERY M. In contrast to Continental Europe. and not for their hurt or for any wrong. Rarely a day passes now without the media focusing on some issue of disputed medical practice. but all too often when problems occur they become accountable. The next he is condemned as authoritarian or uncaring. the Declaration of Geneva strongly reinforced the Hippocratic Oath on this issue. However. Confidentiality In 1947. It is surprising how often this is overlooked in postgraduate courses and texts. Public opinion will affect our patients perceptions.J. All healthcare workers should therefore remain constantly vigilant. whilst the practice of defensive medicine should be condemned. This chapter summarizes the key medicolegal issues and in particular their application to the practice of otolaryngology and head and neck surgery. even after the patient has died’. The vast majority of cases of breach of confidentiality occur inadvertently. It is appalling to contemplate the treatment of patients on the basis of what will be the least likely to land the practitioner in court.’ Hippocratic Oath The aims of the medical practitioner may be laudable. confidentiality is not currently enshrined in statutory law in the UK. there are many complex pressures brought to bear on practitioners to leading them to consider breaching confidentiality. medical ethics or medical litigation. • consent. One day the doctor is hailed as the saviour.

Under the terms of the Bolam test. The legal position on whether. Consent is implied. The person who obtains the consent should. if not. whenever possible. the patient should be consulted and a new form should be signed. Consent should be countersigned and dated by the same person who gave the explanation. In the Sidaway case. In some cases a practitioner may reasonably omit to mention a material risk if. or not. If alteration to the consent is needed. Material risk is that to which a reasonable person in the patient’s position would be likely to attach significance. consent to examination. which may result in dismissal. Types of consent. Material risk. The consent form. Doctors should answer any question as truthfully and as fully as possible. to supplement verbal explanation using drawings or diagrams to ensure that the patient has sufficient knowledge to make an informed decision. It may be taken in the out-patients to allow the patient to consider the matter further. 2. Abbreviation on the consent form should be avoided. 4. the court retained the right to over-rule medical opinion if disclosure was obviously necessary for an informed choice by the patient. when a patient undresses voluntarily for examination. It usually falls to the GMC to enforce patient confidentiality on ethical rather than legal grounds. A breach can lead to a charge of serious professional misconduct and erasure from the Register. Oral consent is valid but should be recorded in the case notes. For major procedures. Consent The competent adult patient has a fundamental right to give. investigation or treatment. Negligence Negligence is established if the duty of care of a doctor towards his patient has been breached (that is when a person has not taken reasonable care to avoid acts or omissions which can cause injury and which can reasonably be foreseen). This right is founded on the moral principle of respect for autonomy. Obtaining consent. purpose and material risk of the proposed procedure and. but this needs to be checked again on admission in case there has been a change in the patient’s condition. 3. but also any staff in their employment. The patient must have sufficient time to think of the procedure and should not be taken under any form of duress. 1. he believes that a warning would be harmful to the patients health (therapeutic privilege). a practitioner can expect to avoid liability if the court finds a reasonable body of opinion which would support the practitioner’s decision. written consent is usually obtained. This provides evidence that consent has been obtained and this should be kept safe in the patient’s record. Consent is obtained before the procedure and before sedation. if necessary. . Consent may be implied or expressed in the oral or written form. Express consent is in an oral or written form. should be appropriately qualified and familiar with all the details and risks of the procedure. or take advice. after proper consideration of the patients condition. However. or withhold. negligence that did not cause damage is not sufficient to bring a medical negligence claim. a doctor is negligent in failing to mention a risk to a surgical patient was determined in the UK in the case of Sidaway. In general practice and private practice the doctor is responsible not only for themselves. A surgeon has a duty to explain to the patient in layman’s terms the nature. All staff employed by the NHS may be subject to disciplinary proceedings following a breach of confidentiality.MEDICOLEGAL ISSUES IN ENT SURGERY 163 court may follow any breach. be the one who will do the procedure and. for example.

because the patient had thought that it was 2% loss of his ability to hear clearly not 2% risk of absolute deafness). such as when one hands over care of patients when going on holiday. highlights how important it is that obtaining consent for surgery requires a great deal of clarity. For example. The Bolam test now applies extensively in all areas of medicine. Many complaints arise as a result of poor communication (informed consent. The majority of patients seem to react reasonably to warnings of facial paralysis. but when he had a ‘dead’ ear after the operation. The patient suffered injuries and fractures but because some doctors do avoid muscle relaxants because of their side effects. and indeed often do not understand. The art of good communication also covers the areas of patients calls to you or your secretary. the case of the patient who was told that there is a 2% risk to the hearing. It will do no harm to improve the line of communication by checking with the patient in plain words whether he or she has understood all that has been said. but when they actually understand what it looks like. A clear and honest explanation to the patient often avoids or aborts an imminent complaint. 1957). the patient must know what facial paralysis means and looks like and one must quantify for the patient the percentage of risk and success. lack of communication was evident. lack of clarity. For most patients. In the Bolam case (Bolam vs. Naturally. avoiding medical jargon. Complaints against doctors Complaints against doctors are rising and the main cause for this is lack of or inadequate communication with the patients. unrealistic expectations. again. not necessarily the majority. Therefore. Duty of care can be discharged if the patient is referred to or advice taken from a senior colleague. Failure of communication among the hospital staff can also be a source of complaint. the judge directed the jury that a doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art. Different doctors genuinely vary in their management of an illness. Doctors need to communicate better. to listen to the patient and to speak to the patient in a language which can be understood. One should always believe the patient. standards will change with the passage of time (more progress and knowledge). but a doctor is expected to display the skill and care of a reasonably competent colleague. Patients like to know that he or she is the most important person in your life during the consultation and always want to feel that their personal agenda has been expressed fully during the consultation. including diagnosis. For example. all that is required is an explanation of what happened and why things went wrong.164 OTOLARYNGOLOGY The standard of care provided is not an absolute. treatment and information disclosed to patients to obtain a true consent. Patients’ letters. if possible. reaction is different. This was perceived by him as insignificant. Patients do not like. ECT treatment was given to a patient without a muscle relaxant. whether he or she would like to ask further questions and to ask the patient to get in touch if there is a problem with follow-up arrangements. What to do when things go wrong . medical terms and one needs to speak to the patient clearly when diagnosis and treatment are explained and risks and realistic expectation of treatment are quoted. Patients do not like to be rushed out of the clinic. Frien HMC. This. patients’ suggestions for further investigation or different treatment by correspondence should be respected. it is acceptable to provide different treatment from a colleague as long as it is accepted by a reasonable body of medical opinion skilled in that specialty. Your communication with the patient should also be expressed clearly in the records.

for often that is all the patient or their relatives need. Do not file your copy to the Legal Adviser in the case notes. The most common reason for a completed ENT claim involves some sort of dental damage during an ENT procedure. Never tamper with the patients records. such as untypical presentation of acoustic neuroma. it is naturally very upsetting when a complaint is made against a doctor who treated their patient with the best intent. The common reasons for this are poor technique. Useful advice on this is given by the BAO-HNS. sight. Litigation for delay or failure to diagnose is on the increase. i. For example there has recently been successful litigation in this area by patients receiving ototoxic ear drops. Patients unsatisfied for being hurried out of the consulting room may feel the cause for a complaint. contact the Legal Adviser or Medical Defence Union immediately. Areas where special precautions should be taken are diathermy and laser (burn) and damage to the teeth during endoscopy. But remember not to let self-doubt creep in. Avoid being defensive. not only of the medication but of the options without the medication. They provide invaluable evidence of treatment given in the event of a claim.MEDICOLEGAL ISSUES IN ENT SURGERY 165 • • • • • • • • Explain clearly and honestly what happened. Write clearly in the case notes what happened and what has been said. It is not sufficient to warn the patient who is to undergo mastoid surgery of facial palsy. investigations and pre-operative photography should be documented. such as malignancy. faulty equipment. excess pressure and failure to examine the ear. Medical records which are tampered with or missing may turn a defensible case into an indefensible one. In-patient procedures Good communication in layman’s terms continues to play a major role so that the patient forms realistic expectations. If appropriate. In a busy out-patient department. keep your Legal Advisor informed and keep faith. Areas of litigation in ENT Medical Defence Union figures show that the most common reason for the notification of an ENT claim relates to some form of sensory loss following surgery. Patients receiving systemic ototoxic medication ought to be assessed audiometrically and the risks explained to the patient. A written account of what is said. informed consent can be forgotten and this causes complaint. It is necessary that the patient understands what facial palsy is. continue to keep a good relationship with the patient. Potential harmful effects of prescribed medication should be clearly explained and documented. Similarly. Finally. It can be difficult in others. Failure or delayed diagnosis is particularly risky in certain areas. Figures from general practice show that almost 20% of all claims arise from ear syringing (a procedure often delegated to a practice nurse). Unclear medical notes will not help the case against you. Complete and contemporaneous medical records are essential. Make sure that all swabs are correct after surgery and that bandages are not too tight. keep good records. for things have the habit of not turning out to be as bad as they first appear. 2.e. smell or taste. 1. Outpatients Procedures. the pros and potential problems of oral/topical steroids should always be explained. . Educate yourself further in the subject. Always date clearly any addition to the notes. diminished hearing. because of the pride and faith doctors have in their own profession. give a follow-up appointment.

. No. 13. 1996 revised November 1997.Frien. legal and political issues that affect the way in which we work. Further reading Handbook of Medicolegal Practice. Hospital Management Committee. Butterworth. Journal of MDU.. one should remember that courtesy. competence and communication are the cornerstone of good medical practice (the three Cs). Vol. MDU Consent to Treatment. age. His or her circumstances. Conclusion Although there are exhaustive lists of moral. occupation and type of disease have to be taken into account when taking consent.166 OTOLARYNGOLOGY Each patient is a different individual. 1 February 1997. ethical. Seeking Patients Consent—the Ethical Consideration. Bolam -v. MDU Ltd. 1957. General Medical Council. GMC Publications. 1991.

although hearing in the affected ear invariably tends to deteriorate. the aetiology of this condition still remains unknown. In the early stages of the disease the hearing may return to normal after the attacks. Movement may exacerbate the vertigo so the patient will lie as still as possible during an attack. Episodic vertigo and hearing loss are the main complaints. Nystagmus is present but its direction is not indicative of the side of origin of the symptoms. Pathophysiology Despite mountains of research. but if the condition progresses and attacks recur deafness becomes established and more severe. of a condition characterized of episodic vertigo. Patients are usually seen in the clinic between attacks. endolymphatic hydrops. There is no doubt that a large psychological component exists. although tinnitus and a sense of fullness in the affected ear are not infrequent. The condition is punctuated by frequent remissions and relapses over a time period of many years. Attacks vary in frequency but typically last between 1 and 24 hours and are often associated with systemic upset in the form of nausea and vomiting.MENIÈRE’S DISEASE Menière’s disease has been recognized since the first description by Prosper Menière. The increased endolymphatic pressure leads to an alteration in basilar membrane mobility. tinnitus and deafness. Patients are typically in their fifth decade at presentation with no gender bias. . in 1861. and consequently physical examination is normal. The same pressure increase leads to distortion of the ampullae of the semicircular canals with subsequent vestibular dysfunction. which is thought to give rise to the classical symptoms. resulting in hearing loss and tinnitus. leading to the delicate neural tissues being exposed to potassium-rich and neurotoxic perilymph with further provocation of symptoms. Bilateral disease is thought to occur in about one-third of cases. In severe cases rupture of Reissner’s membrane may occur. there follows expansion of the endolymphatic compartment. Clinical features Menière’s disease accounts for between 10–20% of cases of true vertigo in a typical outpatient population. Regardless of the primary cause. Current theories of aetiology include labyrinthine ischaemia and an autoimmune response following a viral infection. In the long term (10 years) over 75% of patients’ vertiginous symptoms will improve regardless of treatment type.

Betahistine 16 mg t. are frequently prescribed but there is no good study to demonstrate any greater efficacy than placebo in this condition. The simplest surgical procedure is the insertion of a grommet in the affected ear. Vestibular sedatives. The study was blind and demonstrated no significant differences between the two surgical options. by 5 years this figure is down to 60%. climbing from the simple to the complicated. 1. regardless of which treatment modality is ultimately used (i.168 OTOLARYNGOLOGY Investigations An audiogram is essential and may show evidence of a sensorineural hearing loss. maintained for up to 10 years. Surgical. Medical. have been reported. has been shown to give significantly greater symptom control than placebo. Medical treatment should provide adequate symptom control in about 80% of patients. although the morbidity is higher as a neurosurgical approach is required. it can be used as a preoperative assessment of the potential response to conservative surgery. It can also be achieved by the local application of gentamicin at the round . 2. and caloric tests may demonstrate impaired vestibular function. More radical surgery for this condition involves vestibular nerve section.d. The glycerol dehydration test works on the principle that dehydrating the cochlea and thus reducing the endolymphatic hydrops will produce an improvement in the audiogram and the ECochG. and strong psychological reassurance. Control rates of 90%. This procedure is without any logical or scientific support and probably works by placebo effect alone. Diuretics. The vestibular labyrinth may be selectively destroyed by the use of ultrasound. Decompression is achieved by exposing and opening the sac with or without the use of a shunt to provide prolonged drainage. Other causes of intermittent vertigo should also be excluded. A fluctuating sensorineural loss shown on consecutive audiograms over a period of time. such as prochlorperazine and cinnarizine. with an appropriate history. There are causes of this other than Menière’s disease. is good evidence for the diagnosis. This is accomplished via a cortical mastoidectomy approach to the sac as it lies in the posterior cranial fossa. but this technique does also risk cochlear damage. Although 90% of patients report initial satisfactory symptom control.g. in which sac surgery was prospectively and randomly compared with simple cortical mastoidectomy. particularly hearing. strong placebo effect).e. it is essential to exclude a cerebellopontine angle tumour (e. The mainstay of surgery for this condition has been decompression of the endolymphatic sac with the aim of treating the underlying pathophysiological abnormality without destroying the function of the ear. Medical treatment starts with the manipulation of diet in an effort to reduce salt and fluid intake. Management It is important to bear in mind that Menière’s disease is a condition that responds well to a supportive and sympathetic therapeutic approach. but is unpleasant for the patient as it causes nausea and headache. acoustic neuroma). Treatment can be either medical or surgical and can be regarded as a therapeutic ladder. The greatest controversy surrounding endolymphatic sac surgery concerns the Danish sham study in 1981. tinnitus and deafness is sometimes described as Menière’s syndrome. Classically this loss is described as low frequency. which abolishes signals from the troublesome labyrinth while still preserving hearing. but in fact is flat in two-thirds of cases. The triad of symptoms of episodic vertigo..i. are without doubt useful in short-term symptom control and are best prescribed to be taken at the onset of any attack. In those patients with an asymmetrical hearing loss. thiazides in particular. a labyrinthine vasodilator. Electrocochleography may show an enhanced negative summating potential indicative of altered cochlear function.

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window, or by insufflation of gentamicin using an indwelling middle ear catheter. Finally, in those ears with poor hearing a surgical labyrinthectomy may be the procedure of choice. Follow-up and aftercare By the very nature of the condition, these patients are often ‘long-term’ attenders at an ENT department. However, with appropriate support and encouragement, they need not be ‘frequent’ attenders. Further reading
Ludman H. Menière’s disease. British Medical Journal, 1990; 301:1232–1233. Ruckenstein MJ, Rutka JA, Hawke M. The treatment of Menière’s disease: Torok revisited. Laryngoscope, 1991; 101: 211–218. Commins DJ and Nedzelski JM. Topical drugs in the treatment of Menière’s disease. Current Opinion in Otolaryngology and Head and Neck Surgery, 1996; 4:319–324.

Related topics of interest Caloric tests, p. 27; Vertigo, p. 346; Evoked response audiometry, p. 78; Vestibular function tests, p. 350.

NASAL GRANULOMATA

A granulomatous reaction is a specific type of chronic inflammation characterized by the local accumulation of macrophages and their morphologically and functionally diverse derivatives. These comprise the epithelioid cell and multinucleate giant cell. Usually surrounding and interacting with these is a zone of lymphocytes. Most nasal granulomata are formed as a result of specific chronic infections. The most important of these are tuberculosis, syphilis, leprosy and fungal infections. Non-specific granulomata occur when no infectious agent can be defined and comprises sarcoidosis and Wegener’s granulomatosis (WG). The formerly and inappropriately named lethal midline granuloma is now recognized to be a high grade T-cell lymphoma. Wegener’s granulomatosis Wegener in 1939 described a granulomatous disease of unknown aetiology comprising destructive lesions of the upper and lower respiratory tracts and glomerulonephritis. Histological examination showed granuloma formation and necrotizing vasculitis. It is now accepted that only a single system may be affected by the disease or there may be multi system involvement, affecting not only the three classical systems but also virtually every organ in the body including the ear. These are considered to be variations of WG, but no consensus view exists on the nomenclature in these situations. Pathogenesis Current knowledge suggests that an infection, usually viral, in susceptible individuals triggers an immunological response to produce the features of WG. Clinical features In the nose and when active WG classically causes a sanguinous discharge, crust formation and friable ulcerated mucosa. Chest features comprise haemoptysis and dyspnoea. Oliguria and micro or macroscopic haematuria suggests renal involvement. The patient feels weak and lethargic and experiences marked weight loss. Untreated there is a 93% two-year mortality. WG may effect the external and middle ear causing a serosanguinous discharge and a conductive hearing loss. Vestibulocochlear symptoms, a facial palsy and a secondary infection may occur. On examination the appearances are similar to a carcinoma and the diagnosis can only be made by a representative biopsy. Friable, ulcerative lesions in the mouth, oropharynx, and larynx have also been described.

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Investigations A chest radiograph may show single or multiple opacities up to 5 cm in diameter compatible with areas of infarction with or without cavitation. Alveolar infiltrates, pleural opacities or atelectasis may be present. Urinalysis may show red cells, protein and casts. Creatinine clearance declines. Renal biopsy, if indicated, shows focal necrotizing glomerulonephritis and vasculitis. A recent meta-analysis of patients with active WG calculated a sensitivity of 91% and a specificity of 99% for cytoplasmic anti-neutrophil cytoplasmic antibody (c-ANCA). Between 20 and 40% have raised titres against p (perinuclear)-ANCA. Both antibodies are detected by indirect immunofluorescence. Both antibodies are directed against proteinase 3 and therefore low titre samples can be checked by an antigen-specific enzyme-linked immunosorbent assay. These titres parallel changes in disease activity. The classical three system involvement and a representative biopsy of an active area is both necessary and sufficient to make the diagnosis. Random biopsies of normal looking upper respiratory mucosa in subjects suspected of having the disease provide a zero WG diagnostic yield and therefore the biopsy of an active area is stressed. Treatment Long-term, low-dose antibiotic therapy aimed at preventing an infectious trigger or immunosuppressive therapy aimed at dampening the immunological response is the current strategy. Low-dose co-trimoxazole has been shown to prevent relapse in many patients. Septrin has been shown to increase host cytotoxicity and enhance intracellular killing. Cell mediated immunity against viruses involves the intracellular killing of free virus particles and the killing of virus infected cells by macrophages. Co-trimoxazole’s mechanism of action may be to enhance virus killing sufficiently to prevent immune complex formation which causes inflammation and granuloma formation when deposited in the micro circulation (see Related topic). Cyclophosphamide and prednisolone are the current immunosuppressive drugs of choice, the doses of which are adjusted to reduce side effects to a minimum while maintaining remission. In patients with resistant or fulminant disease plasma exchange, high-dose intravenous steroids or extracorporeal immunoabsorption with protein. Disease activity can be monitored by the ESR and serum C-reactive protein level. High grade T-cell lymphoma This was often confused with WG, but with the advent of modern immunocytochemical techniques, a representative biopsy will allow an accurate diagnosis. Clinical features The nasal features are similar to WG but there is little systemic disturbance and in particular no bronchial or renal disease. There is progressive destruction of the mid-facial structures. Untreated the patient succumbs from secondary infection or cachexia. Investigations A representative biopsy will show huge numbers of small cells with a high incidence of mitoses. There may be zones of acute inflammatory cells if a secondary infection supervenes. Necrotizing vasculitis and granuloma formation are absent. As the small cells may represent a poorly differentiated squamous cell

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carcinoma, malignant melanoma, neuroblastoma or rhabdomyosarcoma immunocytochemical analysis is necessary to confirm the diagnosis. Staging should be undertaken by a medical oncologist to determine optimum treatment. Treatment 1. Antibiotics to control secondary infection. 2. Surgical debridement of necrotic tissue. 3. A curative dose of radiotherapy, usually 60–66 Gy in 30 fractions if stage I (localized) disease, followed by further debridement if indicated. 4. Reconstructive surgery to the nose and mid facial regions as required. Syphilis and tuberculosis Only tertiary syphilis produces a granulomatous reaction, the pathological lesion being the gumma. This can invade mucous membrane, cartilage or bone, the bony septum being the site most commonly involved. The usual presentation is nasal swelling, putrid discharge, bleeding and crusting. A red nodular swelling which can be diffuse or localized may be visible. The treponema pallidum haemagglutination test (TPHA) and fluorescent treponemal antibody test (FTA) for syphilis are positive and a biopsy of the lesion shows perivascular cuffing of arterioles by chronic inflammatory cells and endarteritis. There maybe a septal perforation, erosion of the nasal bridge with a saddle deformity, stenosis of the nares or atrophic rhinitis. Tuberculosis and sarcoid affect mainly the cartilaginous septum. In tuberculosis there may be apple jelly nodules around the vestibular skin and signs of pulmonary involvement. Biopsy shows caseating granulomata and acid fast bacilli may show on a Ziehl-Neelsen stain or following culture. Biopsy of a sarcoid lesion shows non-caseating granulomata, angiotensin converting enzyme levels are raised, the Kveim test is positive and there may be evidence of multi-system involvement. Scleroma and rhinosporidiosis Scleroma is a disease affecting any area of the upper and lower aerodigestive tract and caused by a gramnegative diplococcus Klebsiella rhinoscleromatis. It is endemic in India, the Middle East and parts of Africa but unusual in Western countries when it usually arises within the immigrant population. Nasal symptoms are the most common and usually comprise nasal obstruction and foul smelling mucopurulent rhinorrhoea. Signs of a severe bacterial rhinosinusitis with mucosal injection and oedema, and mucopurulent discharge may be present on endoscopic examination. There may be submucosal swelling in the vestibular area. Atrophic rhinitis like crusting and septal perforation may occur in the cicatricial phase. The diagnosis is made by culture of the diplococcus. Mikulicz cells (macrophage with clear cytoplasm containing the encapsulated organism) and Russell bodies (bright-red degenerated plasma cells) are classically seen on histology. Ciprofloxacin or co-trimoxazole are the antibiotics of choice and need to be continued for at least a month as the organism is difficult to kill because of its mucopolysaccaride coat. Rhinosporidiosis is a chronic disease which can affect any skin lined or mucosal surface of the body and occasionally the viscera. It is caused by Rhinosporidium seeberi and it is thought to be a fungus rather than a protozoan. It is transmitted by swimming in infected water. It is most commonly found in India and Sri Lanka. The nose is the mostly commonly infected site and the disease is typically insidious in onset and runs a slow course. In the early stages a thick, sticky nasal discharge may be seen and there is usually a

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history of recurrent epistaxis. Thereafter pedunculated or sessile, soft, injected polyps form typically around the nasal vestibule. The organism has not been cultivated in vitro or transmitted to animals in the laboratory. Chemotherapy is universally unsuccessful and the only treatment is surgery to excise the lesions. Further reading
Van der Woude FJ, Van Es LA, Daha MR. The role of the c-ANCA antigen in the pathogenesis of Wegener’s granulomatosis. A hypothesis based on both humoral and cellular mechanisms. Netherlands Journal of Medicine, 1990; 36:169–171. Rao JK, Weinberger M, Oddone EZ, Allen NB et al. The role of antineutrophil cytoplasmic antibody (c-ANCA) testing in the diagnosis of Wegener’s granulomatosis. Annals of Internal Medicine, 1995; 123: 925–932. Marfatia HK, Kirtan MV. Management of rhinosporidiosis—newer concept. Indian Journal of Otolaryngology Head and Neck Surgery, 1997; 49:73–74.

Related topic of interest Sinonasal tumours, p. 280; Sinusitis, p. 285.

NASAL POLYPS

Aetiology In certain predisposed individuals, any inflammatory nasal condition can lead to marked swelling of the sinus and nasal mucosa. This seems particularly to affect the mucosa in the region of the middle turbinate and middle meatus. When this swelling becomes sufficiently pronounced, polyp formation may result. The initiator of this inflammatory response may be chronic infection, allergy or intrinsic rhinitis, but in some cases the cause is unknown. Recent work suggests that patients who develop nasal polyps have a subtle immunological disorder of the upper (and often lower) airway; co-existent asthma is common. Pathology Pathologically, polyps demonstrate marked oedema of the connective tissue stroma, which also contains a variety of inflammatory mediators such as histamine, prostaglandins and leukotrienes. There is a marked eosinophilic and histiocytic infiltrate and the epithelium displays goblet cell hyperplasia and in some areas a squamous cell metaplasia. A polyp forms when the oedematous stroma ruptures and herniates through the basement membrane. Nasal polyps are rare in childhood, and if they occur one should suspect cystic fibrosis or immune deficiency. Recurrence is common after surgical removal, although it may often be delayed for many years. It is more likely and tends to occur sooner in those patients with coexistent asthma and aspirin hypersensitivity. Clinical features Nasal polyps may be asymptomatic, but even when small most patients complain of a feeling of congestion or obstruction high in the nose and a hyponasal quality to their speech. As the polyps enlarge there is associated worsening of nasal obstruction and usually a profuse watery nasal discharge causing rhinorrhoea or a postnasal space drip. At the same time patients frequently complain of loss of taste and smell. Headaches, pressure sensation in the face and sinusitis may occur. In severe cases the polyps may be visible at the external nares and widening of the intercanthal distance may occur. The polyps are insensitive. A history of epistaxis or contact bleeding should raise suspicion of the possibility of a neoplastic polyp. Clinical examination of the nose is not complete without an endoscopic examination (rigid or flexible), as without it small polyps in the middle meatus may be missed.

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Investigations There are few essential investigations. It is worth performing skin tests or a PRIST and RAST to identify an allergic cause. Sinus radiographs may be helpful in demonstrating maxillary sinus involvement but are rarely used. In recurrent cases and those to be treated by FESS, coronal CT scanning of the sinuses is essential and provides far more anatomical and diagnostic information. Following surgical removal the polyps should always be sent for histological analysis, especially unilateral polyps or unusual-looking polyps. Management 1. Medical. In patients with small polyps and following surgical removal it is worth trying medical therapy. This consists of intranasal steroids, as either drops or spray, with the addition of oral antihistamines if there is an allergic element. Short courses of low-dose oral steroids may be extremely useful in those patients with particularly aggressive polyposis. 2. Surgical. If sufficiently troublesome surgical clearance can provide marked symptomatic improvement. Good symptom control can be obtained with a ‘simple’ intranasal polypectomy under either local or general anaesthetic. It is likely that a more thorough clearance can lead to better longer-term disease control and so an ethmoidectomy may also be performed. The majority of surgeons would now probably undertake this procedure endoscopically. With appropriate preparation of the operative field and the excellent vision afforded by the endoscope, an exceptionally thorough clearance can be undertaken. This is now often augmented with the aid of powered suction and microdebriders. Computer-aided navigation systems for ethmoid sinus surgery are available and may increase safety in difficult regions, such as the frontal recess. Follow-up and aftercare In simple cases no long-term follow-up is required after the first post-operative check; the patient can be asked to return should future problems arise. Intranasal steroids have been shown to reduce recurrence in the first year and may make a difference to the recurrence rate given long term. In severe cases oral steroids may be needed following surgery. Periodic surveillance and follow-up are usually required. Antrochoanal polyp The antrochoanal polyp is uncommon. It is typically unilateral and commences as oedematous lining from the maxillary sinus. This lining prolapses through the ostium into the nasal cavity and enlarges towards the posterior choana and nasopharynx. The patient, commonly a young adult, complains of unilateral nasal obstruction, which is worse on expiration owing to the ball valve-like effect of the polyp in the posterior choana. If sufficiently large, it may produce bilateral obstruction and cause otological symptoms as a result of blockage of the Eustachian tube orifice. Anterior rhinoscopy may look normal as only the thin stalk may present in the nose. The enlarged posterior end may be seen on posterior rhinoscopy. All suspected cases should therefore have proper endoscopic examination. A CT scan is the best investigation, but a plain sinus radiograph of the maxillary sinus may show complete opacification of the affected antrum.

176 OTOLARYNGOLOGY Treatment is by complete nasal avulsion with removal of the antral portion. p. 131. 6:41–46. Related topics of interest Allergic rhinitis. 11. Failure to remove the antral lining may result in a recurrence. 108. and Mackay IS. p. p. 1998. Current Opinion in Otolarygology and Head and Neck Surgery. Further reading Rowe-Jones JM. p. . Functional endoscopic sinus surgery. Sinusitis. This can usually be achieved endoscopically. With recurrence a Caldwell-Luc procedure may be required to clear the sinus. An intranasal antrostomy is the usual approach. Management of nasal polyps. Intrinsic rhinitis. 285.

which are pushed under the frontal bones. It is appropriate in uncomplicated cases to reassess the patient 5–7 days after the injury. road traffic accident and sports injuries. CSF leak and facial bone fracture. turning up the tip of the nose and revealing the nostrils. a noticeable deformity and nasal airway obstruction are the usual complaints. Injury to the nose may result in a combination of soft-tissue injury. It is important to carefully record the time and nature of the trauma. A class 3 fracture indicates that the velocity of the trauma has been even greater and results in a nasal fracture which extends to include the ethmoid labyrinth. A class 2 fracture is nearly always due to lateral trauma and results in a horizontal (Jarjavay fracture) or C-shaped fracture of the septum involving the perpendicular plate of the ethmoid and the septal cartilage in combination with a fracture of the frontal process of the maxillae. Classification of fracture of the nasal bones An isolated nasal fracture is usually caused by low-velocity trauma. fracture or dislocation of the septum. haematoma and swelling may make the assessment difficult. There is a marked depression of the nasal bones. If the nose is fractured by high-velocity trauma then facial fractures are often an accompaniment. Ocular movements should be tested and Vth . The perpendicular plate of the ethmoid rotates backwards and the septum collapses into the face. Remember to enquire about any trauma to the head and neck and any other injuries.NASAL TRAUMA The commonest causes of nasal trauma are assault. Nasal trauma does not imply only nasal fracture. note any deformity and exclude a septal haematoma. septal haematoma. A history of trauma to the midface accompanied by epistaxis. It should be remembered that the most important consideration in maxillofacial injuries is the maintenance of an airway. Nasofrontoethmoid fractures may produce symptoms of diplopia and epiphora. Nasal fractures are classified on a 1–3 scale depending on their severity and extent. Clinical features Trauma to the nose may be part of a more extensive injury to the facial skeleton and base of skull. Check the nasal airways and examine the septum. Tenderness. and there is an apparent widening of the space between the eyes (telecanthus). The nasal swelling is often accompanied by periorbital and subconjunctival ecchymosis. A class 1 fracture is usually due to a frontal or fronto-lateral blow and results in a vertical fracture of the septum (Chevallet fracture) with a depressed or displaced distal portion of the nasal bone. fracture of the nasal bones. previous episodes of trauma and whether the nasal deformity is new or old.

It may follow nasal trauma. Class 2 fractures have a propensity to redisplace owing to overlapping of the fractured ends of the septal cartilage and the perpendicular plate of the ethmoid. Wounds are thoroughly cleaned and any foreign body removed. but in more serious injuries radiographs are an important investigation.178 OTOLARYNGOLOGY nerve function (infraorbital sensation) and dental occlusion should be checked. 4. Investigations In the majority of simple uncomplicated fractures no investigations are required. If this is missed or not treated correctly. This is due to a collection of blood beneath the mucoperichondrium of the nasal septum. Manipulation should never be delayed for more than 2 weeks post injury because the nasal bones will fix and reduction will be difficult if not impossible. Treatment is not required in some patients because there is no fracture or bony deformity. one blade in the nasal cavity and the other outside. Aspiration may suffice if the haematoma is small. The patient should be given a course of antibiotics to reduce the risk of local and systemic infection. The septum is approached through a Killian incision with the aim of pulling the rotated septal cartilage forwards and downwards. They are also important for medicolegal purposes. The depressed nasal bones need to be elevated out of the face and supported with wires via an incision over the nasofrontal angle. It is possible to reduce a simple class 1 fracture under local anaesthetic before any swelling appears if it is seen early enough. Cerebrospinal fluid leaks. If the fracture is seen later and there is much swelling. Soft-tissue injury. They should include views of the skull. A class 3 fracture will require an open reduction. The presence of clear rhinorrhoea at any stage following nasal trauma should raise the suspicion of a CSF leak. Nasal fracture. Management 1. All injuries should be carefully documented in the case notes supplemented with drawings and occasionally photographs. Abrasions are best left open. submucosal resection (SMR)) and. which will approach that of serum levels. but it can also occur as a complication of septal surgery (e. 3. 2. It is also inappropriate to try and manipulate a long-standing deformity as this will inevitably result in failure. These patients should be reassured and reviewed again when swelling has subsided. They may be important for medicolegal purposes. but larger lacerations should be closed with fine monofilament sutures. The manipulation of the nasal bone should be accompanied by an excision of the septal fracture and overlapping segments through a Killian incision. blood dyscrasias. The elucidation and documentation of these clinical symptoms and signs should be standard medical practice. A CT scan on bone setting may delineate maxillofacial fractures when there is uncertainty. The cribriform plate is extremely thin and is the commonest area of fracture. but incision and drainage with quilt suturing (to obliterate the dead space) is required if the collection reaccumulates. cartilage necrosis and nasal saddle deformity may ensue. or alternatively 2-transferrin assays (this is a protein present in perilymph and CSF) can be used. Septal haematoma. manipulation should be delayed for 5–7 days. rarely. Appropriate antibiotic and antitetanus cover should be given. a septal abscess. Fluorescein injected into the CSF via a lumbar puncture can be collected . Confirmation of the diagnosis is obtained by checking the glucose content of the rhinorrhoea. There is usually complete bilateral nasal obstruction caused by a soft swelling. Small lacerations can be closed with Steristrips. Malunion following nasal trauma will require treatment by a formal septorhinoplasty procedure. face and nasal bones depending on the extent and severity of the injury. Disimpaction and realignment can usually be achieved with laterally applied digital pressure and Walsham’s forceps.g.

2:37–41. . a trans-septal route. 1994. Current Opinion in Otolaryngology and Head and Neck Surgery. fascia lata or a mucosal flap from the nasal septum. 278. Vuilleriun T. Many leaks will close spontaneously. Septal perforation. by an intranasal endoscopic approach or by a frontal craniotomy and repair with reduction of the bony fragments. Related topics of interest Examination of the nose. p. Until the leak ceases the patient is at risk of pneumococcal meningitis and most advocate oral penicillin and sulphadimidine as antibiotic prophylaxis. p. 1–36. Further reading Gleeson M. Scott-Brown’s Otolaryngology. 84. High-resolution CT scan may delineate the fracture. Some suggest that antibiotic prophylaxis is not required. 6th edn. 1997.NASAL TRAUMA 179 from the leak in the nose. Imola M. Fractures of the facial skeleton. but some will require surgical repair with temporalis fascia. Vol. Bull TR (eds). 4. London: Butterworth. In: Mackay IS. Repair can be approached by an external ethmoidectomy. Nasal and sinus trauma.

the male population of which comprise the world’s highest at risk population group. Nasopharyngeal carcinoma Pathology NPC can be divided into three subtypes based on the World Health Organization (WHO) classification. • WHO type 2b is undifferentiated carcinoma. Aetiology The consensus view supports the proposal that in the genetically predisposed a carcinogen is triggered by an environmental co-factor to transform nasopharyngeal epithelial cells. NPC cells consistently express two species of EBV proteins. The latter has a predilection for those of Southern Chinese or Hong Kong extraction forming 20% of all malignancies in these people and 80% of their head and neck cancers. Latent Epstein-Barr virus (EBV) infection is endemic in this group and the evidence for EBV being the carcinogen is compelling. .NASOPHARYNGEAL TUMOURS There are four important groups: a) b) c) d) Nasopharyngeal carcinoma (NPC). Southern Blot and Polymerase Chain Reaction consistently detect DNA sequences of EBV in NPC cells. 2. • WHO type 2a is nonkeratinizing squamous cell carcinoma. The environmental factor most widely implicated is salted preserved fish. a staple diet of the Hong Kong boat people. Angiofibroma. EB nuclear antigen 1 and latent membrane protein 1 detectable by immunofluorescence. It divides the cancer on the basis of its light microscopy appearance. Adenoids (see Related topics). Other nasopharyngeal tumours. In particular: 1. • WHO type 1 is keratinizing squamous cell carcinoma.

The polymerase chain reaction to EB virus genome has been used to diagnose NPC in patients with a malignant neck node with an occult primary. Investigations The diagnosis is made from the history. Plasma antibodies to viral capsid antigen and to early antigens (one of which is an EBV DNAse) are seen. • Superiorly through the foramen lacerum to cause paralysis of the 3rd. vocal cord. examination and special investigations. CT is the investigation of choice to assess skull base and paranasal sinus involvement. . Genetic factors The human leucocyte antigen allele A2 without BW46 or B17 7 is associated with long term survival. shoulder and tongue paralysis and pain. NPC often spreads submucosally from the fossa of Rosenmüller so that no nasopharyngeal abnormality is visible although there may be metastatic lymph node disease. Clinical features The majority of patients present with a history of epistaxis. A chest radiograph. a bone scan are useful screening tools in the search for distant metastases. NPC usually arises from the fossa of Rosenmuller and may spread by direct extension to involve: • Anteriorly to the Eustachian tube causing a serous otitis media. liver ultrasound and. nasal obstruction. The A2 BW46 allele combination is associated with intermediate term survival while the occurrence of B17 is associated with short term survival. Seventy per cent of patients will have metastatic lymph node involvement at presentation and in a large Hong Kong series this was the mode of presentation in 40% of patients.NASOPHARYNGEAL TUMOURS 181 3. pharyngeal. It has recently been shown that EBV is associated with all WHO types of NPC. titres of the latter being a significant predictor of tumour relapse after radiotherapy. A ‘blind’ biopsy is not recommended as the specimen obtained may be non-representative. MRI imaging including a short tau inversion recovery (STIR) sequence to suppress fat clearly defines the tumour margins in soft tissue and will best define the presence and extent of metastatic neck disease. a neck lump or referred otalgia. Involvement of the former space causes mandibular nerve paralysis with partial loss of facial. Involvement of the latter space containing the cervical sympathetic trunk and the IX-XII cranial nerves causes Horner’s syndrome. facial hypoaesthesia and headaches. 4th and upper two divisions of the 5th cranial nerves causing diplopia. • Postero-laterally through the pharyngobasilar fascia to the parapharyngeal and retrostyloid space. palatal. if symptoms dictate. Fibreoptic pharyngoscopy is probably the most reliable method of examining the nasopharynx and should be used if a biopsy of the fossa of Rosenmüller is to be obtained under a local anaesthetic. palatal and pharyngeal sensation and involvement of the pterygoid musculature causing trismus.

N2 Bilateral metastasis in lymph node(s) measuring 6 cm or less in greatest dimension above the supraclavicular fossa. The 5-year actuarial survival is greater stage for stage in WHO type 2a and 2b patients compared to those with WHO type 1 histology. In 1997 the 5th Edition of the AJCC Cancer Staging Manual brought the AJCC into line with the UICC and their staging is: T1 T2 Tumour confined to the nasopharynx. There is evidence that adjuvant chemotherapy reduces loco-regional relapse and significantly improves prognosis in NPC (actuarial five year survival 64% v 42% in radiation alone group). hypopharynx or orbit. Surgery plays a limited role in the treatment of NPC. Management Radiotherapy using a field which includes the nasopharynx. Europe had traditionally used the UICC system. the Ho system. including Hong Kong. Tumour extends to soft tissue of oropharynx and/or nasal fossa.182 OTOLARYNGOLOGY Staging Several staging systems have been developed for NPC which has made it difficult to compare treatment results using differing modalities and results between centres. infratemporal fossa. In high risk areas screening nasopharyngeal biopsies for viral genomes is useful for determination of high risk individuals. N0 No regional lymph node metastasis. In selected patients. N3a Metastasis in lymph node(s) greater than 6 cm in diameter. the sphenoid and posterior ethmoid sinuses. salvage surgery may be indicated for nasopharyngeal recurrence. N3b Metastasis in lymph node(s) in the supraclavicular fossa. and posterior orbit is the treatment of choice. NX Regional lymph nodes cannot be assessed. NPC and in particular undifferentiated NPC is highly radiosensitive so a neck dissection is indicated only for radiotherapy failures even if patients present with N3 disease. T3 Tumour invades bony structures and/or paranasal sinuses. . skull-base. N1 Unilateral metastasis in lymph node(s) measuring 6 cm or less in greatest dimension above the supraclavicular fossa. North America the AJCC system and Asia. Radical neck dissection may control radio-resistant nodes and post-radiation cervical node recurrence. T4 Tumour with intracranial extension and/or involvement of cranial nerves. Prevention 1. T2a: without parapharyngeal extension. The consensus view now is to irradiate the neck bilaterally to reduce the incidence of future neck node metastases. T2b: with parapharyngeal extension (parapharyngeal extension denotes postero-lateral infiltration of tumour beyond the pharyngo-basilar fascia). EBV infection of the nasopharynx is not a regular feature in healthy EBV virus carriers. Counselling this group on their diet and the need for frequent regular follow-up is recommended.

It may expand laterally into the pterygopalatine fossa. T-cell lymphoma. foramina and tissues. In particular it must not be confused with a large adenoid pad. It occurs predominantly and perhaps exclusively in young adult males. is currently undergoing Phase 1 trials. chordoma). the greater wing of the sphenoid and the skull base foramen. The commonest symptoms are epistaxis and nasal obstruction. Other nasopharyngeal tumours • Non-Hodgkin’s lymphoma. meningocele). • Extramedullary plasmacytoma (predilection for the nasopharynx and paranasal sinuses). dysontogenetic (craniopharyngeoma. Infectious mononucleosis. cavernous sinus and orbit may also occur. Angiofibroma This histologically benign tumour comprising fibrous tissue with a variable proportion of vascular tissue. neuroectodermal (encephalocele. Hodgkin’s lymphoma. teratomas). A vaccine based on the EBV envelope glycoprotein GP340. Presenting signs are similar to NPC except there is a smooth mass filling the nasopharynx on endoscopic or mirror examination. paranasal sinuses. If they are disease free then for most cancers they may be considered cured (adenoid cystic carcinoma and malignant melanoma are notable exceptions).NASOPHARYNGEAL TUMOURS 183 2. A high index of suspicion for any nasopharyngeal mass is essential because angiofibroma should not as a rule be biopsied. . Clinical features The tumour expands to erode or compress surrounding fissures. parasellar region. Anterosuperior expansion into the nasal cavity. a major target for the virus-neutralizing antibody response. • Paediatric nasopharyngeal tumours: ectodermal (dermoids. Many head and neck units will continue to follow patients annually for another five years because such patients are at significant risk of developing a second primary cancer. The sphenopalatine foramen is always involved and may be the specific site of tumour origin. every three months for the third year and six monthly for the fourth and fifth years post treatment. bimonthly for the second year. expanding superiorly to erode the pterygoid plates. Other EBV associated disease • • • • Burkitt’s lymphoma (a monoclonal B cell non-Hodgkin’s lymphoma). Follow-up and aftercare All patients with treated head and neck cancer must be reviewed monthly for the first year. through the pterygomaxillary fissure and into the infratemporal fossa. often with large endothelial spaces. arises from the posterolateral wall of the nasal cavity and the superolateral nasopharyngeal wall.

Fagan JJ. Geara FB. Head and Neck Surgeons. Nasopharyngeal angiofibromas: selecting a surgical approach. . Effective Head and Neck Cancer Management. Prasad U. Pathmanathan R. ethmoid and sphenoid sinus endoscopic approaches compare favourably with external approaches with significantly reduced morbidity. For tumours where involvement is limited to the nasal cavity. American Journal of Otolaryngology. 16:103–108. 1989. 29. Gooneratne S et al. nasopharynx. Snyderman CH. Carrau RL. Large vascular tumours require digital subtraction angiography to define the important feeding vessels. Surgery is the treatment of choice for all but the smallest tumours as they may continue to expand and are typically poorly radiosensitive. Induction chemotherapy followed by radiotherapy versus radiotherapy alone in patients with advanced nasopharyngeal carcinoma: results of a matched cohort study. These should be embolized 1–2 days pre-operatively. 1995. British Association of Otolaryngologists. Second Consensus. 1997. Cervical lymphadenopathy. p. Reddy SP. 19:39–399. if the cribriform plate is involved. Prognostic significance of keratinization in nasopharyngeal carcinoma. Raslan WF. 1997. 79: 1279–1286. Wilson J (ed). Cancer.184 OTOLARYNGOLOGY Investigations and treatment An MRI scan with a STIR sequence is the investigation of choice to define the extent and vascularity of the tumour. 8. 15:357–360. Depending on tumour extent a mid-facial degloving or. Glisson BS. European Journal of Surgical Oncology. Sanguineti G et al. a craniofacial approach are those most widely advocated and these may need to be combined with an infratemporal approach. 2000. p. Related topics of interest Adenoids. Janecka IP. Serological markers in the diagnosis of histopathological types of nasopharyngeal carcinoma. Further reading Sam CK. Head Neck.

or it can be performed in continuity with removal of the primary tumour as an en bloc resection. The operation may be required to remove the nodes alone.e. Radical neck dissection is considered to be the standard basic procedure. (a) Supraomohyoid neck dissection. However. The prognosis for the patient regardless of the site of the primary tumour is worse if there are cervical lymph nodes involved at presentation. 2. a superior mediastinal dissection in patients with subglottic or cervical oesophageal tumours). . Extended radical neck dissection involves removal of additional lymph node groups or nonlymphatic structures relative to the radical neck dissection (i. Patients who have larger nodes are less likely to be cured by radiotherapy and must be treated surgically. 3. which can be kept in reserve for the treatment of any recurrence. which form an efficient barrier to the further spread of the disease. (d) Anterior compartment neck dissection. Modified radical neck dissection. 1. Only 30–40% of such patients will survive longer than 5 years. and all others represent one or more alterations to this procedure. It is suggested that this term be used in preference to functional neck dissection. The advantage of using radiotherapy in these cases is that it precludes the need for surgery. which should be abandoned. Classification The classification below is suggested by the American Academy’s Committee for Head and Neck Surgery and Oncology. Selective neck dissection involves the preservation of one or more lymph node groups routinely removed in radical neck dissection. (c) Lateral neck dissection. Modified radical neck dissection involves the preservation of one or more non-lymphatic structures routinely removed in radical neck dissection. radiotherapy will only be effective in the curative treatment of cervical lymph node metastases if they are less than 2 cm in diameter. Radical neck dissection. The oncologist has two effective treatment modalities for neck node metastases in radiotherapy and surgery. Broadly speaking. Selective neck dissection.NECK DISSECTION A primary carcinoma arising from the upper aerodigestive tract may ultimately drain into the lymph nodes of the neck. (b) Posterolateral neck dissection. for the foreseeable future it is likely that both these terms will continue to be used.

There is preservation of any one or all of the following structures: internal jugular vein. Rupture of the carotid artery (may be a sequel to wound breakdown). marginal mandibular branch of the facial. but the main advantage from this procedure is that the risk of frozen shoulder (due to accessory nerve resection) is avoided. Wound infection. sympathetic trunk. brachial plexus). poor nutritional status). • Haemorrhage (from either end of the internal jugular vein or other ligated vessel). previous radiotherapy. the midline anteriorly and the anterior border of the trapezius muscle posteriorly. Wound breakdown (poor surgical technique. • Frozen shoulder (less likely to occur if the cervical nerve branches of C3 and C4 are preserved as they pass under the fascia of the floor of the posterior triangle). diabetes. Extended radical neck dissection. upper. Intermediate. Radical neck dissection This operation refers to the removal of lymph nodes in the anterior and posterior triangles extending from the inferior border of the mandible superiorly to the clavicle inferiorly. • Nerve palsies (phrenic. Cerebral oedema (after a synchronous or staged bilateral neck dissection). . • Recurrence in the glands or skin. the accessory nerve or the sternocleidomastoid muscle. vagus. • • • • • Facial oedema.186 OTOLARYNGOLOGY 4 . Late. The cervical lymph node groups routinely removed are as follows: submental and submandibular. and the posterior triangle group. The submandibular gland. spinal accessory nerve. middle and lower jugular (deep cervical). hypoglossal. 3. Immediate. lingual. Modified radical neck dissection is considered to result in regional control rates similar to those achieved by radical neck dissection as long as patients are carefully selected (patients with mobile nodes not greater than 3 cm in diameter and no more than 3 in number). • Chyle leak (if the thoracic duct has been inadvertently damaged). Complications of radical neck dissection 1. internal jugular vein and sternocleidomastoid muscle are also removed. Modified radical neck dissection This operation consists of a monobloc removal of the cervical lymph nodes from levels I through to V as with a radical neck dissection. 2. The jugular vein preservation is of great importance when bilateral neck dissections need to be performed.

p. Bilateral synchronous neck dissection carries a significant morbidity and a mortality of about 3%. Many of the complications can be reduced by either staging the procedure with an interval of 6 weeks or longer or performing a modified procedure on the opposite side to preserve the internal jugular vein.NECK DISSECTION 187 Selective neck dissection The selective neck dissections are based on a knowledge of the distribution of nodal metastases in the different primary sites. Ligation of one internal jugular vein results in a threefold increase in the intracranial pressure. Neck dissection. Second Consensus. Removes the nodes around the visceral structures in the midline (level VI) and is usually indicated for thyroid cancer. . 2000. III. III and IV. Lateral neck dissection. The most serious complication is that of raised intracranial pressure. though it never returns to its normal level. Posterolateral neck dissection. 197. Oral cavity carcinoma. be nursed propped up in the bed. but when the second side is tied there is a tenfold increase in pressure. Thus for patients with NO disease the following procedures remain an option: 1. but univariate analysis demonstrates a reduced 5-year survival to around 5%. Current Opinion in Otolaryngology and Head and Neck Surgery. 1991. Hypopharyngeal carcinoma. Anterior compartment neck dissection. p. Robbins TK et al. II and III. 203. 1993. Wilson J (ed). Surgery probably does not influence the natural history of the disease. 117:601–605. Further reading Robbins TK. 2. p. p. Bilateral neck dissection The presence of bilateral neck nodes is not an independent poor prognostic sign. the intracranial pressure tends to fall. 4. Related topics of interest Cervical lymphadenopathy. 1: 114–119. Oropharyngeal carcinoma. Effective Head and Neck Cancer Management. Supraglottic carcinoma with bilateral glands is an exception and can still have a reasonable prognosis. Archives of Otolaryngology and Head and Neck Surgery. The patient should have a temporary tracheostomy. Laryngeal carcinoma. Usually applied for skin tumours such as melanoma and skin adnexal tumours (levels II. p. 3. Standardising neck dissection terminology. and may require an infusion of mannitol (500 ml of 10% mannitol over 4 hours). IV and V). 138. Over the following 8–10 days after the operation. This is because when bilateral disease is present at least one set of nodes is usually of greater diameter than 6 cm and fixed. 29. The most critical period is the first 12 hours postoperatively. For cancers of the larynx and hypopharynx the commonest node levels are II. British Association of Otolaryngologists. 124. Head and Neck Surgeons. Supraomohyoid neck dissection. Oral cavity tumours commonly metastasize to levels I.

The submandibular space is bound by the mucosa of the floor of the mouth superiorly and by the mylohyoid muscle and deep fascia investing the submandibular gland inferiorly. just anterior to the sternomastoid but above the hyoid bone. 1. The pre-vertebral fascia arises from the base of skull in front of the atlas and inserts into the body of T3. both complications of acute suppurative otitis media. although the inflammatory reaction usually localizes the abscess to the retropharyngeal space. An abscess behind this fascia cannot extend below this level unless the fascia is breached. 5. Infection may therefore spread from the prestyloid to the post-styloid compartment by passing medial to the carotid sheath or from the retropharyngeal space to the post styloid compartment (and vice versa) by passing posterior to the carotid sheath. 3. It is emphasized there is no anatomical barrier preventing an abscess tracking inferiorly into the superior and posterior mediastinum. The infratemporal fossa therefore is equivalent to the prestyloid compartment of the parapharyngeal space. The latter contains the carotid sheath. . anteriorly by the posterior wall of the maxilla and superiorly by the infratemporal surface of the greater wing of the sphenoid. The parapharyngeal space is a potential space immediately lateral to the oropharynx and nasopharynx. An abscess in the post-styloid compartment may track further laterally to point just behind the posterior aspect of sternomastoid. Immediately anterior to the pre-vertebral fascia is a potential space extending from the skull base to the diaphragm. have been previously described as has peritonsillar abscess (see Related topics). That portion behind the pharynx is the retropharyngeal space. which is firmly attached on its lateral aspect to the investing layer of deep fascia on the deep aspect of sternomastoid but has only loose areolar tissue lying medially and posteriorly. In the pre-styloid compartment a collection may extend as far forward as the fascia surrounding the submandibular gland. It is bounded posteriorly by the styloid process and the anterior wall of the carotid sheath. 2. The infratemporal fossa lies beneath the base of skull between the side wall of the pharynx and the ascending ramus of the mandible. the styloid process dividing it into an anterior or pre-styloid and a posterior or post-styloid compartment.NECK SPACE INFECTION Anatomy Understanding neck space infections is straightforward but requires some anatomical knowledge. 4. Neck space infections Citelli’s abscess and Bezold’s abscess.

might cause rupture of the abscess with inhalation or tracking of the abscess into the mediastinum. The condition occurs in adults when a prevertebral TB abscess ruptures through the prevertebral fascia. the neck extended to prevent the retropharyngeal soft tissues causing a pseudomass. but it may allow empirical anti-tuberculosis treatment to be instigated while the culture and sensitivity result is awaited. It is safer therefore not to examine the throat which.NECK SPACE INFECTION 189 Prevertebral abscess This is rare today and occurs in adults from tuberculosis of the cervical spine. although in the latter case the history is longer. Suppuration of retropharyngeal nodes occurs after an upper respiratory tract infection (URTI) from lymphatics draining infected tonsils. is highly suspicious of a retropharyngeal or retrotracheal abscess. Aspirating the abscess allows a sample to be subjected to a Z-N stain. pharynx or paranasal sinuses although occasionally the source is an unsuspected foreign body. requiring urgent drainage of the abscess and cord decompression. have stertor or dysphagia. A lateral neck radiograph shows prevertebral soft tissue shadowing and a rarified vertebral body which may be wedge shaped through collapse. An expiratory radiograph in a normal child can also cause widening of the retropharyngeal soft tissues so the X-ray must be interpreted as part of the overall clinical picture before treatment decisions are made. Older children have fewer retropharyngeal nodes and adults have only the node of Rouviere. A positive result does not distinguish between tuberculosis and atypical mycobacterial infection. Investigations An inspiratory lateral soft tissue neck radiograph. Parapharyngeal abscess Sixty percent arise from tonsillitis or peritonsillitis and thirty percent from an abscess of the root of the lower third molar which lies below the mylohyoid line. Symptoms mimic laryngotracheobronchitis and acute epiglottitis. Retropharyngeal abscess The overwhelming majority of cases arise in children less than four years old. teeth. A progressively painful and tender neck with limitation of movement is the usual presentation. The child may need to remain on ICU for 24–48 hours until the retropharyngeal soft tissue swelling settles. The child becomes increasingly toxic and may dribble. even with a correct diagnosis. Treatment It has been suggested that in the absence of airway distress. Mastoiditis or a pharyngeal foreign body are unusual causes. The neck is held rigidly and may become hyperextended. internal jugular vein thrombosis and mediastinitis. . intravenous antibiotics and close observation may obviate the need for incision and drainage of the abscess in the tonsillectomy position. will show the widened retropharyngeal space and narrow oropharyngeal airway. Occasionally collapse will cause acute spinal cord compression. An increase in the retropharyngeal soft tissue density of more than 7 mm or 14 mm in the retrotracheal area. It has potentially life threatening complications including internal carotid artery rupture. The attachment of the fascia limits the inferior extent to the vertebral body of T3.

Gidley PW. . There is trismus. These may obviate the need for formal incision and drainage.190 OTOLARYNGOLOGY Clinical features These are similar to a peritonsillar abscess. 38:263–271. Incision and drainage is necessary if there is not a rapid response to intravenous antibiotics or if the airway is becoming precarious. Submandibular abscess (Ludwig’s angina) In over 80% of patients infection arises from a root abscess of the lower premolars or the first and second molars. Contemporary management of deep space neck infections. 1997. hot. tender swelling which may be firm or fluctuant or diffuse. and the tonsil is pushed medially. The tongue is pushed posteriosuperiorly and there is trismus and dribbling. 1999. Anatomy: regional and applied. 1997. The remaining cases are secondary to tonsillitis. Conley SF. the choice of antibiotics being similar to retropharyngeal and parapharyngeal abscess. 7th edn. This is usually preceded by the insertion of a nasopharyngeal tube to secure the airway. London: Longman. A mixed population of aerobic and anaerobic organisms are usually present. swollen and tender. Further reading Last RJ. Clinical features Floor of mouth oedema secondary to cellulitis can progress rapidly to endanger the airway. Treatment Repeat fine needle aspiration of the abscess and intravenous antibiotics. Treatment If the airway is not in immediate danger fine-needle aspiration of the abscess and intravenous antibiotics are usually adequate. soft palate oedema. red. The submandibular region is red. There may be no history of dental pain if the root is close to the inner table of mandible which gives way early. International Journal of Pediatric Otorhinolaryngology. Pediatric deep neck space infections: the Medical College of Wisconsin experience. 116:16–22. often torticollis. either co-amoxyclav or a broad spectrum penicillin/cephalosporin and metronidazole are the combination of choice. Ghorayeb BY. Flanary VA. There is a hot. Stiernberg CM. It lies most commonly behind the posterior aspect of the upper or middle third of the sternomastoid because infection most commonly drains from the pre-styloid to the post-styloid compartment and there-after laterally. Otolaryngology and Head and Neck Surgery.

330. . 311. p. p. 232.NECK SPACE INFECTION 191 Related topics of interest Acute otitis media. Paediatric airway conditions. 5. Tonsil diseases. p. Stridor and stertor. p.

In the UK the first action level is 85 dB(A) for an 8-hour working day. At the second action level of 90 dB(A). discos and personal stereos. building sites and high-impact tools. Clinical features TTS may be perceived as ringing in the ears (tinnitus) following excessive noise exposure. Permanent threshold shift (PTS) is frequently asymptomatic initially and is often found on routine screening audiometry carried out in the workplace. When PTS becomes symptomatic the first complaint is usually reduced understanding for . with increasing noise levels above 90 dB(A). initially to the outer hair cells (OHCs) of row 1. Motorcycling and car airbags are both recently recognized causes of noise-induced hearing loss (NIHL). Initially noise exposure will lead to temporary threshold shift (TTS). Therefore small increases in noise exposure recorded in dB expose the cochlea to large increases in sound energy. The audiometric hearing loss tends to parallel the loss of hair cells. Such screening is a requirement of any hearing protection programme. A doubling in sound intensity corresponds to an increase of only 3 dB. while a 10-fold increase in intensity corresponds to an increase of 10 dB. such as shooting. such as factory machinery. monitoring and efforts to reduce sound levels at source. There are no obvious pathological changes in TTS and the problem is probably due to metabolic ‘exhaustion’ of the hair cells of the cochlea. home power tools. Gender and increasing age appear to have an influence on susceptibility. at which point an employer is obliged to monitor the hearing levels of his work force and to monitor noise levels at the work place. With increasing and repeated noise exposure there is permanent direct mechanical and metabolic damage. a greater proportion of the exposed population will exhibit pathological changes. However. he is statutorily obliged to provide a hearing protection programme to include hearing protection. Occupational deafness is a compensable disease and legislation exists to protect the employee (Health and Safety at Work Act). a recoverable phenomena. Damage also occurs to the supporting pillar cells and the stria vascularis. and subsequently to the OHCs in rows 2 and 3 and the inner hair cells. recreational. Pathology Biological variability means that individuals are not affected equally by the same noise exposure.NOISE-INDUCED HEARING LOSS Aetiology and background The ear is a sound-sensitive organ but can be damaged by excessive noise levels. Excessive noise can arise from a variety of sources: occupational.

regarding the hearing loss and frequent tinnitus. nonsyndromic hereditary and degenerative causes are not uncommon. Examination will reveal normal tympanic membranes (unless the patient has had previous middle-ear disease) and the audiogram will often show a dip at around 4–6 kHz in the early stages. Allowance is then made for any difference between the two ears. age. e. any conductive loss and the type of audiogram. Follow-up and aftercare Continuing advice and review by a hearing therapist is recommended to minimize disability. There are increasing research reports of the use of pharmacological agents to protect the cochlea metabolically from the effects of noise. Current Opinion in Otolaryngology Head and Neck Surgery. Counselling is helpful. Robinson DW. A hearing aid may be required.g. McFadden SL. Management Damage to the cochlea caused by noise is cumulative so that. Personal injury cases are argued on their individual merits. high-tone sensorineural hearing loss or intermittent tinnitus. Management: medicolegal Occupational noise-induced hearing loss (NIHL) became a compensable disorder in 1975. Awareness of the potential hazards of noise will allow prophylactic measures to be taken both at work and recreationally. the use of earplugs and muffs. Investigations A good history is the key to diagnosis and is essential in personal injury medicolegal cases in order to provide apportionment of disability if more than one type of noise exposure has occurred. avoidance of further noise exposure. to minimize disability. and as such a scheme exists to calculate the disability and hence the amount of compensation. This may become exaggerated as exposure continues. and a figure for the disability is finally reached. It is also essential when assessing any claimant with NIHL to consider alternative explanations for the hearing loss. preferably from a hearing therapist. further deterioration must be prevented by adequate protective measures or better still. London: Whurr. Henderson D. Assessment of Hearing Disability. 2 and 3 kHz. 1999. Further reading King PF. especially when there is background noise. Unfortunately tinnitus is a frequent accompanying symptom in noise induced hearing loss. so investigation to exclude this cause is sometimes necessary. 7:266–273. until eventually there is flattening of the audiogram as sensorineural damage progresses. Lutman ME. 1992. Coles RRA. As it becomes more severe the patient complains more of being hard of hearing. once diagnosed. Guidelines for Medicolegal Practice.NOISE-INDUCED HEARING LOSS 193 speech. Recent advances in understanding and preventing noise-induced hearing loss. Cerebellopontine angle tumours may produce a unilateral asymmetrical. . In essence this involves averaging the hearing thresholds for each ear for the frequencies of 1.

254. Impedance audiometry. p. Pure tone audiogram. p.194 OTOLARYNGOLOGY Related topics of interest Acoustic neuroma. 194. p. 128. p. Non-organic hearing loss. 1. .

Unfortunately. e. In the former group the patient usually exaggerates an existing hearing loss in an effort to improve any compensatory payment. Pure tone audiometry. The prelimin-ary clinical investigation may reveal some inconsistencies which suggest the diagnosis.NON-ORGANIC HEARING LOSS Non-organic hearing loss (NOHL) is a condition in which a patient consistently displays an apparent auditory deficit. when no true hearing loss exists. 1. which can also be performed using an audiometer. the Stenger test (see Clinical assessment of hearing.g. so this is not invariably the case. Clinical assessment The diagnosis of NOHL depends primarily on a high index of clinical suspicion. A patient with a genuine unilateral hearing loss would perceive the bone-conducted stimulus in the normal cochlea and report the perception of sound. or in a child with psychological disturbance. ototoxic drugs or trauma). In the truly deaf patient pure tone audiometry reveals consistent results. it has been estimated to occur in up to 25% of cases. 2. There may be recruitment. although it may not always be possible to identify the stressor. The pure tone audiogram itself may be performed in an erratic and hesitant fashion. a non-organic component must be excluded. Investigations A plethora of tests exist to try and distinguish non-organic from organic hearing loss. in whom there is an ongoing claim for compensation as a result of ototrauma (hearing loss from noise exposure. The patient appears to hear much better than the subsequent audiogram would suggest (but beware of lip readers). or exaggerates a real hearing loss. Patients complaining of a unilateral hearing loss may deny any hearing of a tuning fork placed on the mastoid process of the affected side. Impedance audiometry. Tuning forks. Those patients who have some degree of psychological upset often appear completely unconcerned about the hearing loss but are very often accompanied by an extremely concerned carer. a sound over 70 dB above the threshold applied to the bad ear. 45). the underlying hearing is usually normal. The stapedius reflex threshold normally varies from 70 to 95 dB above the pure tone threshold. These can be used as part of the clinical assessment in cases of apparent unilateral hearing loss. In the child. in all patients who are pursuing a financial claim. In the latter group this psychosomatic symptom represents a cry for help in response to some current stressful event. This condition is usually encountered either in an adult. One should suspect a NOHL when pure tone responses are inconsistent or when the patient denies hearing. p. in the good ear. particularly financial claims and in children without obvious pathology. Even then there is usually . 3.

2. 301. Noise-induced hearing loss. 6.196 OTOLARYNGOLOGY at least 20 dB between the reflex threshold and the pure tone threshold. Evoked response audiometry. Management The aims in management are first to recognize that there is a non-organic hearing loss and thereafter to ascertain the true auditory thresholds. and an honourable escape route is provided. Non-organic hearing loss in adults. If the thresholds are within 20 dB or less than a NOHL is likely. the NOHL will often disappear on repetition of testing. The voice is recorded and played back into the bad ear via headphones. Impedance audiometry. Delayed speech feedback. If there is a genuine deafness the patient will be able to read without pausing. rarely lasting more than a few weeks or months. Baltimore: Williams & Wilkins. Brooks DN. p. p. Cortical responses are preferred to brainstem evoked responses as they provide precise threshold levels and establish integrity of the entire auditory pathway. as in medicolegal cases. . Fortunately. 254. In: Beagley HA (ed. Oxford: Oxford University Press. 192. Electrocochleography can be used. Any true hearing loss can then be treated on its merits. p. but this technique is invasive and gives no information about the central auditory pathways. Once it is indicated to a patient that the true thresholds are suspected. Follow-up is only required to document the return of normal hearing. Patients pursuing a financial claim are well aware of their actions. Follow-up and aftercare In severe or prolonged cases (up to 20%) appropriate psychiatric referral may be required. Related topics of interest Clinical assessment of hearing. 45. Evoked response audiometry. 78. Non-organic hearing loss in young persons: transient episode or indicator of deep-seated difficulty. Strong reassurance that there is nothing serious present and that the hearing will improve in time is usually all that is required. 26:347–350. successful. if ever. p. disturbed. If knowledge of the auditory thresholds is required with some precision. slow down or shout. Vol. Pure tone audiogram. as the stressing event disappears or the patient develops appropriate coping strategies. electric response audiometry will be required. Patients often find it more difficult to exaggerate their impairment to the same extent in speech as in pure tone audiometry. and compensated accordingly. 1992. p. If the patient is feigning deafness then the delayed speech feedback will alter the reading pattern causing the patient to stammer. A hearing aid may be provided for its placebo effect when there is great distress on the part of the patient or carers. Speech audiometry. This is often useful in making the diagnosis.) Audiology and Audiological Medicine. Downs MP. The patient is asked to read aloud from a book. British Journal of Audiology. Confrontation is rarely. 4. the recording being delayed by milliseconds. Speech audiometry. Further reading Alberti P. 3rd edn. 5. p. 128. 910–931. including the provision of a hearing aid if required. Northern JL. Hearing in Children. in the younger. 1984. 1981. group the condition is usually short lived. Geoghegan PM.

salivary gland and connective tissue origin occur in the oral cavity. The tongue has a well-developed lymphatic drainage. difficulty in eating and speaking. The remainder include adenoid cystic carcinoma. . tumours of the lateral border of the tongue spread to the jugulodigastric nodes. the upper and lower alveoli. They usually present as an ulcer but may protrude as an exophytic-type lesion. which are in the oropharynx. Alveolar tumours may interfere with dentures. Tongue mobility and dental hygiene should also be noted. Other aetiological factors include smoking tobacco. halitosis and. Most patients are over the age of 40 years with a peak incidence in the sixth and seventh decades. and high alcohol consumption. a warty growth. but the incidence of occult metastases is high (35%). particularly in a pipe. There is also an increased incidence in patients with cirrhosis of the liver. The incidence of squamous cell carcinoma of the oral cavity varies worldwide. Over 90% of the malignant tumours are squamous cell carcinoma. which are present in nearly a third of patients at the time of presentation. On examination the site. The male to female ratio is 2:1. the anterior twothirds of the tongue and the floor of the mouth to the anterior tonsillar pillars. sarcomas and melanomas. The commonest sites are the lateral border of the tongue and the floor of the mouth. Tumours of the anterior floor of mouth and alveoli tend to spread to the submandibular nodes. but also occur in other sites in the head and neck. Second primary tumours occur in up to 30% of patients with oral cavity carcinoma. mucoepidermoid tumours. Tongue tip tumours spread to the submental lymph nodes first. The neck should be examined for nodal metastases. It does not include the posterior third of the tongue. but in India it accounts for more than 40% because of the common practice of chewing betel quid containing tobacco. In the UK it accounts for less than 2% of all malignancies. Clinical features The patient may complain of a painful ulcer. and those from the posterior oral cavity tend to metastasize to the jugulodigastric nodes.ORAL CAVITY CARCINOMA The oral cavity consists of the buccal mucosa. the hard palate. soft palate or tonsils. They are most commonly found in the oral cavity. Pathology Although benign tumours of epithelial. the oesophagus and in the lungs. Some tumours present with no nodes palpable (NO). later. size and extent of the tumour should be assessed. but some anterior tumours may spread directly to the jugulo-omohyoid nodes. the majority are malignant.

MRI scans are not good for illustrating bone invasion but they are particularly useful in the soft tissue delineation of tongue tumours. However. All patients should have an examination under anaesthetic to obtain a biopsy. A chest radiograph is mandatory to exclude lung metastases. The disadvantages of external beam radiotherapy are: it cannot be used again at the same site. Radiotherapy can also be used for T1 and small T2 tumours. Tumour more than 2 cm but less than 4 cm in its greatest dimension. and patients may require a full dental extraction prior to treatment. Larger tumours of the tongue need a partial or total glossectomy. can be repaired with a radial forearm free flap. The patient is spared the ordeal of surgery and maintains good oral function. removing up to half of the tongue. T3 and T4 tumours. 2. can then be planned. muscle. Tumour with extension to bone. skin. Management The management of all patients depends on the site and size of their tumour. check the neck for nodes and stage the disease. T1 and T2 tumours. exclude a second primary. the extent of local and distant spread. salvage surgery for radiotherapy failure has a low survival and high morbidity. Nutritional status and the need for percutaneous gastrostomy should be assessed. . they are not specific and consequently there is a significant false positive rate. loss of taste and mucositis can be troublesome side-effects. 1. Surgery is as efficient as radiotherapy in the treatment of T1 and T2 tumours. Prior to treatment all patients should see a dentist/prosthodontist to assess the status of the teeth. xerostomia. TNM classification Tis T1 T2 T3 T4 Carcinoma in situ. etc. Tumour more than 4 cm in its greatest dimension. It is important to remember that the surgery required can impair the functions of swallowing and speech besides its effect on the appearance of the patient. evaluate the tumour. Tumour 2 cm or less in its greatest dimension. Oromandibular function impairment is often quoted as an argument against surgery. A combination of external beam and implants can be used. A partial glossectomy. The aim of surgery is to resect the disease while maintaining maximal function and cosmesis. Therapy. Small tumours of the alveolar margin can be treated by a marginal mandibulectomy. Primary radiotherapy should not be used to treat tumours involving the mandible as later excision of the bone may lead to osteoradionecrosis. the presence of any intercurrent disease and their general condition.198 OTOLARYNGOLOGY Investigations An orthopantomogram may demonstrate involvement of the lower alveolus by the appearance of a motheaten rim or an opacity of the normal lucent dental canal A CT scan is also useful to delineate the extent and local spread of these tumours. including the feasibility and nature of a surgical resection. Isotope bone scans are very sensitive for the presence of mandible invasion. If more than half of the tongue is removed it should be reconstructed by a pectoralis major myocutaneous flap or a rectus abdominus free flap. They should also be referred to a speech therapist for counselling in respect of their postoperative speech and swallowing rehabilitation. With some of the larger T2 tumours a radial forearm free flap may be necessary. Small tumours can be resected transorally using a cutting diathermy or CO2 or KTP laser with primary closure or closure with a quilted split-skin graft. but some quality of life studies support surgery as the primary modality for these lesions.

especially with anterior oral cavity lesions and those located in the midline. surgical excision of the primary tumour and modified radical (preferable) or radical neck dissection is the treatment of choice. Further reading Wildt J. In some cases no nodes are palpable (NO) but the incidence of occult metastases is high (35%). Most surgeons advocate the use of postoperative radiotherapy. Therefore in all (but the very smallest T1 tumours) cases of oral cancer. Because of lymphatic crossover. large primary tumours (large T2. In addition. The radial forearm or composite fibula flap are usually used. Palliative treatment. If much of the anterior segment of the mandible is removed the soft-tissue and bony defect should be reconstructed with a composite osteocutaneous free flap. 4:98–105. T3 and T4). Current Opinion in Otolaryngology and Head and Neck Surgery. it may be inappropriate to subject elderly. Level IV should therefore be resected for these tumours (‘extended’ supra-omohyoid neck dissection). If there is going to be a recurrence it is likely to be in the first year. 1989. Clinical Otolaryngology. 2:343–347. 14:10–13. The donor sites of grafts and flaps should be checked until they have healed. 5. but the decision to treat other than for palliation should be carefully considered. and speech therapy may be appropriate in some cases.ORAL CAVITY CARCINOMA 199 preserving the outer cortex of the mandible. Current Opinion in Otolaryngology and Head and Neck Surgery. 1994. Postoperative radiotherapy. two or more positive nodes and whenever there is extracapsular spread. Patients should have a monthly outpatient review for the first 6 months and then every 2 months for 6 months. Follow-up and aftercare The highest mortality is in the first 2 years after diagnosis. A supra-omohyoid neck dissection (levels I. The oral cavity and neck should be carefully examined for signs of recurrent disease. perineural or intravascular invasion. Neck nodes. consideration should be given to treatment of both sides of the neck. infirm patients who are in poor general condition. Some patients who have a large tumour with advanced local spread or with distant metastases will not be suitable for curative treatment. et al Squamous cell carcinoma of the oral cavity: a retrospective analysis of treatment and prognosis. or who have severe intercurrent disease. DeLacure M. II and III) is the usual procedure. the prognosis is poor. Special considerations in management of the mandible for cancer of the oral cavity. The risk of a second primary tumour should be remembered. 3. Tongue lesions seem to metastasise to levels II and III more often. If the patient has palpable neck node metastases. Soft tissue reconstruction of the oral cavity and pharynx. Intense prosthodontic rehabilitation should be given where appropriate. Shindo ML. . If the patient has bilateral neck node disease. then three monthly for the second year. but a partial mandibulectomy may be required. Zaretsky L. T3 and T4 lesions do badly when treated by radiotherapy alone. poor histological differentiation. 4. 1996. The nutritional status and weight of the patient should be monitored. Irradiation to both sides of the neck or bilateral neck dissections with preservation of one internal jugular vein are possible. elective treatment to the first echelon nodes should be given either by radiotherapy or selective neck dissection. to radical treatment These patients should have supportive nursing care and when necessary adequate analgesisa for pain relief. to be given within 6 weeks of surgery. This is effective in reducing primary recurrence and has been shown to improve survival when: there are positive margins.

British Association of Otolaryngologists. Head and Neck Surgeons. Related topics of interest Oropharyngeal carcinoma. Reconstructive surgery. 264. 2000. Second Consensus.200 OTOLARYNGOLOGY Wilson J (ed). Effective Head and Neck Cancer Management. . 203. 267. p. p. p. Radiotherapy.

The diagnosis can be established by passing a probe through the fistula into the antrum. Trauma. Clinical features The patient may complain of symptoms of chronic maxillary sinusitis. Dental extraction. A fistula may also follow the search for retained root fragments after a tooth has been broken. Biopsy is needed if neoplastic disease is suspected. . An oroantral fistula is a communication between the oral cavity and maxillary antrum. The injection of a contrast medium into the defect is helpful in confirming the presence of a fistula in doubtful cases. foreign bodies.OROANTRAL FISTULA Definition A fistula is an abnormal communication between two epithelial-lined surfaces. Neoplasm. The incision line fails to heal. Fractures of the maxilla or penetrating wounds such as a gunshot injury of the hard palate. the roots of which may penetrate the floor of the antrum. 2. 4. especially in the cases of neoplasia. A CT scan will improve delineation. Purulent discharge may collect in the nose or mouth and a foul smell or taste is often noticed. Its incidence is probably higher than is recognized because many fistulae escape diagnosis following dental extraction and heal spontaneously without complications. A patient who has previously had inferior meatal antrostomies may notice that air or fluid and food particles can be sucked through the fistula into the nose. particularly of the first upper molar and second premolar teeth. Investigations Radiological examination by sinus radiography and orthopantomogram may show retained root fragments. 3. Caldwell-Luc operation. signs of erosion by neoplastic disease or infections of the maxillary sinus. Malignant disease of the antrum may occasionally cause erosion into the oral cavity. Aetiology 1. The fistula forms through the tooth socket following a dental extraction.

Diseases of the oral cavity. The patient should be reviewed in the outpatient department monthly until healing is complete. 363–365. For those following dental extraction the most satisfactory treatment is immediate suture at the time of the dental treatment. 280. Sinonasal tumours. Further reading Snow GB. If the fistula has not healed it will need formal surgical closure. The patient should give consent for this. If there is evidence of chronic sinus infection an antrostomy. Pus should be sent for culture and sensitivity and a generous meatal antrostomy carried out under antibiotic cover in order to aerate the sinus and allow drainage of pus or secretions. The adjacent buccal mucosa or a palatal flap based on the greater palatine artery may be used.202 OTOLARYNGOLOGY Treatment The important factors determining treatment are the length of time the fistula has been present and the presence or absence of infection. Related topics of interest Pharyngocutaneous fistula. should be fashioned at the same time as the fistula closure. Follow-up and aftercare Decongestant nose drops and a broad-spectrum antibiotic should be prescribed for the first postoperative week and the choice revised according to culture results. Van Der Waal. p. Stell PM (eds) Clinical Otolaryngology. The bare area is then covered by a mucoperiosteal flap. The infection should be treated first. The fistula tract is incised circumferentially around the margins of the fistula and turned inwards. In: Maran AGD. 249. . this must be removed or treatment will be unsuccessful. Oxford: Blackwell Scientific Publications. If adjacent teeth cause a problem in closure they should be removed. p. The patient should be reviewed 4 weeks later. When a fistula is discovered later there will nearly always be friable granulation tissue in the tract and possibly an antral infection. If there is a retained root. 1979. Any foreign body must be removed and the bony edges of the alveolus reduced. if not present.

Most soft palate MSG tumours are pleomorphic adenomas. . Pathology • • • • 85%: Squamous cell carcinoma (SCC). Lateral wall: anterior and posterior tonsillar pillars and the palatine tonsil. Ninety-five per cent of NHL involves the palatine or lingual tonsil. Anterior wall: posterior third of tongue and vallecula.g. rhabdomyosarcoma. Most MSGC arises from the lateral wall. Betel nut chewing. Carcinoma < 2 cm at largest dimension. Carcinoma > 4 cm at largest dimension. 3%: Others e. 2%: Minor salivary gland carcinoma (MSGC). Staging summary Tx Tis T0 T1 T2 T3 Tumour cannot be assessed. No primary evident. Posterior wall: from the level of the hard palate to the aryepiglottic folds. Carcinoma in-situ. Thirty per cent of SCC patients will have either a synchronous second primary or will develop a metachronous second primary within 10 years of presentation. Carcinoma >2 < 4 cm at largest dimension. The lingual surface of the epiglottis is now classified as being a subsite of the supraglottis (UICC 1997).OROPHARYNGEAL CARCINOMA Boundaries • • • • Roof: oral surface of the soft palate and uvula. of these 50% are adenoid cystic. smoking and in smokers alcohol (not proven to be a risk factor alone) are risk factors. 10%: Non-Hodgkin’s lymphoma (NHL). Leukoplakia and in particular erythroplakia are pre-malignant. There is a male : female ratio of 5:1 for SCC.

radiotherapy may be used. oesophagus. If disease is limited to the tonsil a tonsillectomy is performed in order to obtain macroscopic clearance. It is preferred to CT scanning. 2. adreomycin. With many T4s macroscopic clearance is not possible. Investigations 1. 3. Management Most oncologists treat medium and high grade NHL as a disseminated disease and the CHOP regime (cyclophosphamide. a stepped paramedian mandibulotomy is necessary in order to preserve the inferior dental nerve. To obtain adequate exposure of the lateral oropharynx. A panendoscopy under general anaesthesia is necessary to properly assess the hypopharynx.204 OTOLARYNGOLOGY T4 Carcinoma extending beyond oropharynx. If involvement up to and including the mandibular periosteum has occurred an inner table mandibulectomy is performed. A full head and neck examination is mandatory because of the high incidence of a second primary. fitness and wishes. In the relatively unusual event that the lymphoma is very localized. An MRI scan with a STIR sequence will accurately define the extent of soft tissue invasion and neck node involvement. Trismus is a late symptom and suggests pterygoid involvement.g. 4. Sore throat. cyclophosphamide and bleomycin) is a more recent regime favoured by some oncologists. NHL requires assessment by an oncologist to properly stage the disease. Clinical features Twenty per cent of patients present with a neck lump as the only symptom. VAPEL-B (vincristine. referred otalgia. into the pterygoid muscles. hard palate. level. looking abnormal compared to its partner. number and fixation of any palpable neck lump(s). etoposide. Chemotherapy or radio-therapy may reduce tumour size for clearance to be attempted but this will depend on the patient’s age. Palpating the tumour and the neck is important to assess the extent of infiltration of the primary and to assess the size. Fine needle aspiration cytology (FNAC) of any palpable neck lump. oncovine (vincristine) and prednisolone) is the most commonly favoured. odynophagia and muffled speech are common. Large T2 and T3 stage disease is treated with surgery. SCC is either exophytic or ulcerative but with NHL the tonsil is either large and vascular or small and shrivelled. MSGC and SCC require a macroscopic margin of 1–2 cm and clearance must be confirmed by frozen section. The exact site is determined after assessing an orthopantomogram as the incisor and canine roots are often not parallel. mandible. Suspicious tongue base lesions always require a deep biopsy as the cancer may be submucosal. deep muscle of tongue or/and larynx. If a neck lump is not palpable but is defined on MRI or CT imaging FNAC should be performed under either ultrasound or preferably CT guidance. One canine and an incisor may need to be extracted at mandibulotomy to ensure the plating screws do not impinge on a root thereby predisposing to a root abscess. e. A chest X-ray and liver ultrasound are performed as these are the commonest sites for distant metastases. prednisolone. osteomyelitis and non-union of the plated mandible. trachea and bronchi for synchronous disease. hydroxydaunorubicin. T1 and small T2 stage SCC can be treated with radio-therapy as can N1 neck disease. Should the dental canal be involved a partial mandibulectomy is performed with reconstruction using a composite radial .

OROPHARYNGEAL CARCINOMA 205 fore-arm (if less than 10 cm of mandible is taken). Bilateral elective neck irradiation or bilateral selective neck dissection (levels I-IV) should be considered. T1 and small T2 posterior wall SCC can be irradiated. Teknos TN. excision with at least a 1 cm margin may allow reconstruction of the posterior wall with a radial forearm fasciocutaneous microvascular free flap allowing the patient to keep their larynx. Head and Neck Surgeons. Effective Head and Neck Cancer Management. T2 tongue base SCC may be excised after a paramedian mandibulotomy by a midline tongue split or via a lateral pharyngotomy after exposing the structures in the post-styloid compartment of the parapharyngeal space. Cassisi NJ (eds) Management of Head and Neck Cancer. 6: 268–271. 2000. . consideration should be given to elective neck therapy as there is a high risk of occult neck involvement in oropharyngeal disease. Soft palate oropharyngeal cancer should be irradiated if small but larger tumours require a partial soft palatectomy with reconstruction using a radial forearm fasciocutaneous microvascular free flap which gives the best result in terms of function and cosmesis. Management of the neck In the NO neck. Strictures at the anastomosic line in those who have had a stomach transposition are unusual but may require repeated dilation. normally on around the 10th post-operative day. A radical neck dissection is required for N3 disease. Oropharynx. If a recurrence occurs. Rehabilitation so that sufficient fluid and nourishment can be swallowed to maintain homeostasis can take many weeks and in these a percutaneous gastrostomy is preferable to nasogastric feeding. 401–431. The pre-epiglottic space in large tongue base cancer is almost certain to be invaded so that the only oncologically safe procedure is a total glossolaryngectomy with oral and pharyngeal reconstruction with a pectoralis major myocutaneous flap. Current Opinion in Otolaryngology and Head and Neck Surgery. Wilson J (ed). Cassisi NJ. 2nd edn. Follow-up and aftercare After surgery swallowing is frequently seriously impaired. In: Million RR. Philadelphia. extracapsular rupture or positive margins). 1994. JB Lippincott. The regularity of follow-up is the same for any head and neck cancer and is outlined elsewhere (see Related topics of interest). Oropharyngeal reconstruction. Swallowing rehabilitation should be instituted by a speech therapist with a special interest in swallowing as soon as nourishment is allowed by mouth. 1998. Large posterior wall SCC is rare and is probably best treated by a total laryngopharyngo-oesophagectomy and reconstruction with a stomach transposition. a composite fibula or a composite deep circumflex iliac microvascular free flap. The neck and primary site may be irradiated in N1 neck disease with a small primary. Any mucosal irregularity in this region must be biopsied in case there is underlying recurrent disease is. Further reading Million RR. A modified radical neck dissection is used for N1 and some N2 neck disease when surgery is the treatment of choice for the primary. British Association of Otolaryngologists. Second Consensus. Postoperative radiotherapy may be required (more than one node involved.

. 267. 197. p. Laryngeal carcinoma. 124. Oral cavity carcinoma. p. Radiotherapy. p.206 OTOLARYNGOLOGY Related topics of interest Hypopharyngeal carcinoma. Reconstructive surgery. 264. p. p. 138.

by virtue of involving bone. acute otitis media. It is important to remember that otalgia may arise from a primary neuralgia of any of the sensory nerves. neoplasms. The pain may emanate from the pinna. It may be caused by primary disorders of the ear (otological in origin) or may be secondary to disease from other sites in the head and neck which share the same sensory innervation (referred pain). 2. It is a symptom not a diagnosis. myringitis bullosa (Coxsackie B virus infection). Pinna. The external auditory meatus and lateral tympanic membrane receive their supply from the auriculotemporal nerve and branches of the facial and vagus nerves (Arnolds nerve).OTALGIA Otalgia is pain in the ear (earache). The upper half receives its supply from the lesser occipital nerve (C2) medially and the auriculotemporal nerve laterally (mandibular branch of Vth cranial nerve). Malignant otitis externa (pseudomonas infection) and tumours. lacerations. shingles. perichondritis. otitis externa. predominantly C2 and C3. may also produce severe pain. Less commonly the pain may be centred in the external auditory meatus and not be induced by throat movement. IX and Xth cranial nerves) also causes neuralgic type pain. The medial aspect of the tympanic membrane and middle ear is supplied through the tympanic plexus by the facial and glossopharyngeal nerves (Jacobsens nerve). The lower half of the pinna receives its sensory supply from the great auricular nerve via the cervical plexus. Primary otalgia Primary otalgia arises as a result of direct stimulation of the sensory nerves due to otogenic pathology. 3. . neoplasms. the external meatus or middle ear. 1. This condition gives rise to severe lancinating pain arising in the tonsillar fossa or tongue base and radiating deeply in the ear. Anatomy The sensory nerve supply of the external and middle ears arises from many sources. Trauma from ear cleaning. Secondary (referred) otalgia Referred otalgia may arise from disease in any peripheral territory supplied by the nerves. although it is most common in the glossopharyngeal nerve. Haematoma. furuncles. acute mastoiditis. Middle ear. Shingles of the ear (herpes zoster oticus—VII. often induced by talking or swallowing. chondrodermatitis nodularis helicis. External auditory meatus. Traumatic perforation of the tympanic membrane.

• Dental disease such as tooth impaction. Assessment A full history and examination will normally direct attention to the offending part of the head and neck. 2. 3. • Tumours of the tongue base. In cases where doubt exists. • Arthritis/cervical spondylosis. A trial of carbamazepine or amitriptyline may benefit the patient. pharynx and larynx. • Almost any oropharyngeal infective process may lead to otalgia. Management Appropriate treatment should then be directed at the underlying cause. Trigeminal nerve (Vth cranial nerve). This condition may be successfully treated by tympanotomy and section of the tympanic plexus. • Carcinoma of the larynx and hypopharynx. glossopharyngeal neuralgia). 1. scans may be appropriate (e. tonsillitis and quinsy. Particular attention should be paid to the tongue base. but obvious on an MRI scan). particularly of posterior teeth. as pathology here can be catastrophic if overlooked. It is not uncommon to find a small group of patients with otalgia shuttling back and forth between ENT and oral surgeons.g.g. and in those in whom there are absolutely no abnormal findings. In such cases. Otalgia is common following tonsillectomy. • Soft tissue injury. it is worth reconsidering a neuralgia (e. Vagus (Xth cranial nerve). Glossopharyngeal nerve (IX cranial nerve). • Nasopharyngeal disease such as viral infection. the temperomandibular joints. except perhaps some mild clunking of the temperomandibular joint.208 OTOLARYNGOLOGY Causes A brief list and system of classification for the commoner causes of referred otalgia is given below. a small adenoid cystic carcinoma of the tongue base may not be apparent on examination. . Second and third cervical nerves (C2 and C3). the neck and the oral cavity. such as pharyngitis. with both claiming the symptom is in the other’s department. 4. caries and abscess. Occasionally. tumour or post adenoidectomy. no abnormality can be found even after a thorough examination and further investigation. The examination should include the ears. and temporomandibular joint dysfunction are probably the commonest non-otological causes of otalgia. • Sinonasal disease and salivary gland disease are uncommon causes of referred otalgia.

p. . 5.OTALGIA 209 Further reading Cook JA. p. Irving RM. 104: 114–117. Journal of Laryngology and Otology. Related topics of interest Acute suppurative otitis media. Facial pain. p. Otitis externa. 209. 97. 1990. Role of tympanic neurectomy in otalgia.

aureus and Proteus. hot. S. especially from dirty fingernails. parakeratosis and spongeosis. The skin of the bony ear canal lacks appendages and thins from without in. lying on a thin dermal bed containing sweat glands. The epithelial reaction consists of vesication. . bathing. Perichondritis. swimming. • Trauma. oedematous and tender ear canal. Sweat gland secretions keep the secretion at a pH between three and five which is lethal for most human pathogens. humidity. usually caused by S. cotton buds and hairgrips. Pathology The skin of the EAM comprises in the outer third an epithelial layer containing hair follicles. Usually the EAM is sterile or contains Staphylococcus albus commensals. Classification 1. • Inherited—narrow ear canals and non-atopic eczema. In the acute phase of otitis externa there are dilated dermal blood vessels of increased permeability which cause signs of a red. Erysipelas caused by Streptococcus pyogenes. aureus. Malignant otitis externa.OTITIS EXTERNA Definition Otitis externa is an inflammation of the skin of the external auditory meatus (EAM). The secretions of the sebaceous glands keep the stratum corneum water-tight and supple. Predisposing factors • Heat. ceruminous glands and sebaceous glands. aeruginosa or occasionally S. aureus. Furunculosis. Staphylococcus aureus and non-haemolytic streptococci are unusual. Infective (a) Bacterial Diffuse otitis externa commonly caused by Pseudomonas aeruginosa. usually caused by P.

Otalgia occurs with furunculosis. Aspergillus niger Aspergillus fumigatus Candida albicans (c) Viral Herpes simplex Herpes zoster Presumptive in otitis externa haemorrhagica. and herpetic infection. Conditions affecting the ear canal are limited and a diagnosis can usually be made on examination. Secondary to an acute or chronic otitis media. In the former there is postauricular tenderness localized to a palpable lymph node. excess squamous debris suggests chronic eczema or mycosis and hypertrophic meatal skin suggest chronic disease It is not uncommon to find the ear canal occluded by oedema in a patient with acute otalgia. Vesication occurs in eczema. diffuse otitis externa and herpes infections. Psoriasis. an infection of the superficial layers of the epidermis. Plain lateral-oblique and Towne’s projection mastoid radiographs may show mastoid air cell coalescence in acute mastoiditis but in this and furunculosis the mastoid air cells may be cloudy on the lateral view. for example tonsillitis and sinusitis and preceding symptoms of otitis media should be sought. atopic tendency and previous otological problems should be made. mycosis or acute trauma. seborrhoeic dermatitis. Exceptionally this node may break down to cause diffuse tenderness and oedema which may displace the pinna slightly forwards and there is always pain on moving the pinna. Eczema. neurodermatitis or mycotic infection. swimming habits. Localized infection can be circumscribed or diffuse while generalized infection can be either primary otological or primarily dermatological. A patient with acute mastoiditis will have a more marked post-auricular swelling which may be fluctuant. Clinical features Otitis externa may be confined to the meatus (localized) or involve other areas of skin (generalized). Seborrhoeic dermatitis. Inquiries regarding direct trauma to the ear canal. displacing the pinna down as well as forwards. There is no pain on moving the pinna and there will be a preceding history of acute suppurative otitis media. Keratitis obturans. . Although the history may provide a pointer towards the diagnosis.OTITIS EXTERNA 211 (b) Fungal (c) Viral Impetigo. Symptoms of infection elsewhere in the head and neck. usually by S. pyogenes. severe itching suggests eczema. On examination erythema is a feature of eczema. Reactive. In furunculosis this is because post auricular oedema is superimposed on the plate. Careful examination will usually distinguish furunculosis (common) from acute mastoiditis (now much less common). aureus or occasionally S. 2. Neurodermatitis.

Splinting will be necessary when there is EAM oedema preventing an adequate view of the tympanic membrane on otoscopy implying that ear drops will not reach the deeper recesses of the ear canal. Splinting the meatus. The dressing should be changed at least every 48 hours until the canal swelling has settled sufficiently to allow any applied drops to reach the anteroinferior recess directly. Its low pH is lethal for many bacteria including pseudomonas. the hygroscopic action of which reduces meatal swelling or a pope’s sponge earwick onto which eardrops containing an antibiotic and steroid mixture are applied. The diagnosis is often not considered until a cranial nerve palsy has developed. and antibiotic/ antimycotic sensitivity. sigmoid sinus thrombosis. Swimming is inadvisable and precautions taken when bathing to prevent water entering the ear canal. The two recommended choices are 12 millimetre ribbon gauze. Follow-up and aftercare Treatment should continue for at least one week after resolution because of the tendency to recurrence particularly in otomycosis. including fungal culture. malignancy of the EAM or middle ear and malignant otitis externa. CSOM. brain abscess and death. The condition should be suspected in a patient with granulation tissue deep in the external meatus which does not settle with the usual treatment. 2. The ears should be kept scrupulously dry until resolution. Management 1. Histological and microbiological examination of granulation tissue. Itchy reactive conditions may benefit from a course of beclomethasone ear drops and an 8% solution of aluminium acetate or acetic acid ear spray is recommended in patients with chronic otitis externa after the acute infection has been eradicated. Malignant otitis externa This condition describes an otitis externa which progresses to an osteomyelitis initially of the tympanic plate which then may spread to involve the skull base and petrous portion of the temporal bone. When such a patient develops a facial nerve palsy the differential diagnosis is between the ASOM (almost always secondary to a dehiscent horizontal portion of the facial nerve). It is most common after middle age. Meticulous and regular aural toilet paying particular attention to the anteroinferior meatal recess. In most reactive conditions the above regime is also recommended in order to prevent secondary infection of a raw ear canal surface. The overwhelming symptom is a constant deep otalgia and it may cause 7–12th cranial nerve palsies.212 OTOLARYNGOLOGY Investigations A culture swab should be taken for microbiological culture. . 8% aluminium acetate ear drops which act as an astringent may be considered. impregnated with 10% ichthammol in glycerine. and a high definition CT scan of the petrous temporal bone are required to make the diagnosis. In resistant cases.aeruginosa. 3. in diabetics and is usually caused by P. meningitis.

Vol. . Further reading Hammond V. 89.). The dose and duration of treatment is decided after discussion with a senior microbiologist and by monitoring clinical response but often therapy has to be continued for six weeks or more. Diseases of the external ear. Related topics of interest External ear conditions. Scott-Brown’s Otolaryngology. Opiate analgesia may be required to control the deep otalgia.OTITIS EXTERNA 213 Treatment Appropriate intravenous antibiotics as gleaned from the culture and sensitivity results should be commenced. 5. Acute otitis media. p. 1997. Even with aggressive treatment there is still a significant mortality. In: Booth JB (ed. London: Butterworth. p. 3. 6th edn. Chronic otitis media. 38. p.

allergy and reduced overall nasopharyngeal dimensions. The adenoid is recognized as an important contributor to otitis media with effusion (OME) because it is a source of pathological bacteria. There is no difference in effusion rates between those children who have large versus small adenoids. tenacious mucus rich in glyco. The tympanic membrane can look dull red. Examination may or may not reveal a middle-ear effusion depending on the activity of the process at consultation. The prevalence is also higher in the winter months. Pathology The prevalence of OME is highest in young children (40% at 2 years) and decreases with age so that it is uncommon in teenagers (1% at 11 years). punctuated by numerous remissions and relapses. In a small number of persistent and severe cases there is progressive atrophy and retraction of the tympanic membrane. in those with allergy and in the children of parents who smoke.and mucoproteins and containing inflammatory cells which fill the middleear cleft. It can bulge forward or be retracted. with the more severe cases tending to present earlier. Clinical features The presence of fluid in the middle-ear cleft leads to a conductive hearing loss of variable severity and is responsible for most of the clinical features.OTITIS MEDIA WITH EFFUSION (GLUE EAR) Aetiology The fundamental pathology is Eustachian tube dysfunction. and recurrent infections and otalgia are uncommon features of this condition (1–2%) although they are common complaints in childhood. parental smoking. Hearing impairment. This ultimately causes an inflammatory response in the middle-ear mucosa and the production of glue: thick. noticed by parents. but there are associations with recurrent upper respiratory tract infections. Learning difficulties and speech delay account for the bulk of the remainder. in boys. Attic and posterior retraction . grey or an amber yellow colour. In most cases (90%) spontaneous resolution is the rule. in children with cleft palate or Down’s syndrome. The otoscopic appearance of the effusion varies. The exact cause for this remains in doubt. whether persistent or intermittent. and not because it mechanically obstructs the orifice of the Eustachian tube. Sequalae such as retraction pockets and even cholesteatoma may ultimately develop. The underlying Eustachian tube dysfunction leads to a chronic reduction in middle-ear pressure. Most cases present between the age of 3 and 6 years. relatives or teachers or picked up at routine screening is the presenting symptom in over 80% of cases.

Grommets should be used rather than T-tubes. Medical treatment has little role to play in this condition: antihistamines and decongestants have no useful effects and antibiotics produce short-term improvements. in particular a persistent hearing loss. Maw AR. The benefits of ventilation tubes may be augmented by combination with adenoidectomy. 1988. Bawden R. Auto inflation of the Eustachian tube using the Otovent device has been shown to give useful results. In the more severe cases the insertion of ventilation tubes improves hearing and shortens the overall duration of the condition. but bony erosion is relatively unusual. The benefits of adenoidectomy are greatest between the ages of 4 and 8 years. but is significantly less effective than grommets. A sizeable proportion of affected children (25%) will require further subsequent grommet insertion. There is no good evidence that swimming with unoccluded ears increases the risk of infection. 13: 171–177. For many children explanation and reassurance to the parents are all that is required. Further reading Maw AR. Tiwari RS. Investigation An audiogram appropriate to age and impedance audiometry are all that is required. Grommets extrude after approximately 9–12 months following which some form of review is required to recheck the hearing. The main complications of grommets are infections and the development of tympanosclerosis (which is found in 30– 40% of children 1 year after grommet insertion). 306:756–760. Impedance audiometry will show a flat tympanogram (type b) which is typical of otitis media with effusion and helps distinguish the disease from Eustachian tube dysfunction and otosclerosis.OTITIS MEDIA WITH EFFUSION 215 pockets may occur. Pure tone audiometry if feasible will show a conductive hearing loss. but grommet removal may be required if the condition fails to settle. Children with glue ear: how do they present? Clinical Otolaryngology. 1993. Spontaneous resolution of severe chronic glue ear in children and the effect of adenoidectomy. Tonsillectomy does not seem to influence the condition. Air bubbles or a fluid level can occasionally be seen. which are associated with an unacceptably high rate of residual perforation (up to 50%). Management Management should be appropriate to the severity of the symptoms and should always take account of the natural history of the condition towards spontaneous resolution. Tympanosclerosis is associated with multiple episodes of grommet insertion and intratympanic bleeding at myringotomy. tonsillectomy and insertion of ventilation tubes (grommets). British Medical Journal. A review visit after 3 months is useful to establish the persistent nature of the patient’s condition. but do not affect the long-term course. Follow-up and aftercare Grommets require little aftercare. although some form of ear plug should be worn when shampooing (soap reduces the surface tension of the water). Compliance can also be a problem. Infections should be treated by aural toilet and antibiotic/steroid ear drops in the first instance. . mini-grommets seem to cause less but tend to extrude sooner.

. p. Paediatric hearing assessment. p. Tympanosclerosis. 239. 128. p.216 OTOLARYNGOLOGY Related topics of interest Impedance audiometry. 344.

These outer hair cell vibrations can be detected in the external auditory meatus as otoacoustic emissions. These are low-level signals which occur without external acoustic stimulation in about 40–50% of the normal hearing population.7 and 4 kHz. Sound vibrations pass from the environment through the external and middle-ear systems to cause vibrations of the cochlear perilymph. Acoustically evoked OAEs are almost never found in ears with a hearing level worse than 40 dB. outer hair cell vibrations can be detected in the external auditory meatus as otoacoustic emissions (OAEs). They appear to have little clinical or research use. Although they are relatively constant in frequency. they vary in terms of occurrence and intensity and consequently have little use in clinical monitoring. High frequencies are represented at the basal turn and low frequencies at the apical portion. This mechanism allows the finetuning found in the healthy cochlea. 3. Types of otoacoustic emissions Four classes of OAE exist: 1. have a motor function. The inner hair cells are purely sensory and are responsible for detecting these vibrations and producing neural impulses to allow them to be perceived by the central nervous system as sound. thickness and consequently stiffness of the basilar membrane. These are recorded at the frequency of a stimulating pure tone. These signals. these travelling waves reach maximal amplitude at specific points along the cochlea.OTOACOUSTIC EMISSIONS Using modern computing technology and signal averaging techniques. Stimulus-frequency OAEs. The signal is very different for each individual but remains fairly constant for any given ear. occur in response to short-lasting stimulatory acoustic signals (usually clicks or tone bursts). The outer hair cells also detect these vibrations but. Transient evoked OAEs (TEOAEs). Physiology The cochlea provides an elegant mechanism for transforming the physical properties of sound into electrical neural impulses. usually between 0. in contrast. These vibrations produce travelling waves in the basilar membrane. They were first described by David Kemp in 1978 and represent an objective measure of cochlear function. These vibrations are detected as a result of shearing forces on two separate hair cell systems in the organ of Corti: the inner (IHCs) and outer (OHCs) hair cells. The outer hair cells at the region of maximal travelling wave amplitude vibrate in synchrony with the stimulating signal while the OHCs on either side of this region suppress vibration of the basilar membrane. As a result of the gradient of width. Spontaneous OAEs (SOAEs). TEOAEs occur in almost all human ears with . 2.

1992. Stimulation with two pure tones of specific frequency and intensity ratios gives rise to DPOAEs. Related topics of interest Evoked response audiometry. 1993. The acoustic stimuli are usually broadband clicks. Research is still being undertaken into the optimal method of producing and subsequently analysing OAEs. British Journal of Audiology. Unlike a tympanometer. 1997. easy to test and do not require an anaesthetic. but are of greater amplitude and wider frequency range in children. The stimulated signals are then received and fed to a signal processor where. at a maximal rate of 50/s. by the use of appropriate frequency filters and time window averaging. OAE measurement. an airtight seal is not required. Further reading 3rd International symposium on cochlear mechanisms and otoacoustic emissions. The sensitivity and specificity of the test is sufficiently good that there are widespread recommendations that all newborn infants are screened for hearing loss by OAE prior to discharge from hospital. Clinical uses Although still a research tool for the investigation of cochlear function. Paediatric hearing assessment. Harris FP. Distortion-product OAE (DPOAE). . OAEs can be demonstrated on either a visual or print-out display. Evoked OAEs are quick. 78. Probst R. in contrast to electrical evoked response audiometry. they are finding increasing use for clinical screening and research. As they are relatively quick and easy to measure. These characteristics make them an ideal tool for investigating frequencyspecific cochlear function. 53:182–204. the use of evoked OAEs has now found a place in clinical practice in the screening of neonates and high-risk infants for hearing loss. p. 27(2): 71–159. 4. Advances in Oto-Rhino-laryngology. p. They are nearly always present in normal hearing ears and can be measured in the 6–8 kHz range. Otoacoustic emissions.218 OTOLARYNGOLOGY hearing levels better than 40 dB. 239. An OAE analyser consists of a mobile probe which contains a sound emitter and microphone for recording.

intracerebral (cerebellar and temporal lobe) abscess or haematoma and otitic hydrocephalus. including degloving injuries. Middle ear • Tympanic membrane haematoma and petechiae. • Haemotympanum and acute non-suppurative otitis media.OTOLOGICAL ASPECTS OF HEAD INJURY A blow to the side of the head by a blunt or sharp instrument may cause injury to the external. • Acute suppurative otitis media. Otitis externa. meningitis. Loss of pinna tissue. Intracranial complications—lateral sinus thrombosis. Conditions caused by such trauma are described below. External ear • • • • • • Subperichondrial haematoma. External auditory meatus stenosis. middle or inner ear in isolation or in combination. Inner ear • • • • Perilymph fistula from either a round window rupture or from the oval window. Serous or a purulent labyrinthitis. Labyrinthine ‘concussion’. . There may be a fracture of the temporal bone and other skull base fractures. extradural. • Ossicular chain discontinuity. • Tympanic membrane rupture with or without the deposition of squamous epithelium within the middle ear. Perichondritis. • Facial nerve injury. subdural. Occlusion of the external canal by clot.

Over 80% of temporal bone fractures involve a combination of both longitudinal and transverse fractures. Sequelae are unusual in longitudinal fractures and a conductive hearing loss is unlikely to be due to a traumatic ossicular discontinuity. the only sign will be bruising of the postauricular skin (Battle’s sign). raised intracranial pressure and focal neurological signs. The fracture extends across the long axis of the petrous bone through the labyrinthine capsule and is demonstrated with plain temporal bone radiographs in 50% of cases. 1. nystagmus to the opposite ear. Transverse fractures. usually a dead ear. Clinical features Longitudinal fractures tear the skin of the external auditory meatus and tympanic membrane to cause swelling of the canal skin and bleeding from the ear. A sensorineural hearing loss is usually secondary to inner ear concussion and therefore temporary. In 80% of temporal bone fractures a longitudinal fracture is the dominant fracture and usually arises from a lateral blow to the skull. A haemotympanum and ruptured tympanic membrane will occur if the fracture line extends to the middle ear cleft. 2. Management The general management of the head injury takes precedence but it is important to avoid introducing infection into the ear so prophylactic antibiotics are often indicated. depending on the orientation of the fracture line to the long axis of the petrous temporal bone. These fractures occur with a more severe head injury so otological symptoms may not become apparent until recovery from the acute head injury.220 OTOLARYNGOLOGY Temporal bone fractures These are classified into longitudinal. Occasionally with a fracture of the squamous temporal bone. The fracture extends from the squamous temporal bone in the roof of the bony external auditory meatus to the tympanic membrane and the roof of the middle ear before turning anterior to the labyrinth where it may involve the carotid canal. IXth to XIIth cranial nerve injury. This usually heals without residual conductive deafness if infection is prevented. transverse and mixed. Longitudinal fractures. Facial nerve injury occurs immediately in half of these fractures. Labyrinthine capsule disruption causes an irreversible sensory hearing loss. These findings should be presumed to indicate such a fracture following a head injury. . The latter is suspected when an initial serosanguinous aural discharge becomes clear. In a pure transverse fracture there is a haemotympanum but no bleeding from the ear because the tympanic membrane remains intact. It should resolve when the ear canal skin and tympanic membrane heal. Symptoms of secondary endolymphatic hydrops may be caused by involvement of the vestibular aqueduct in the fracture line. a type of longitudinal fracture. severe vertigo. Temporal bone fractures often have a mixed longitudinal and transverse component and this will be suspected from combined clinical features. Facial nerve injuries are uncommon although CSF otorrhoea is more common with this fracture. An isolated longitudinal or transverse fracture is unusual. In the absence of a facial palsy the ear should be left untouched in the early post injury period. This is the dominant fracture in 20% of temporal bone fractures and usually arises from a blow to the front or back of the skull.

Even if there was no fracture then a neuropraxia or axonotmesis may have occurred and early decompression may prevent further injury to the nerve. Related topics of interest Facial nerve palsy. A high definition CT scan of the temporal bone on bone setting with fine (1 mm) cuts is required. If there is a fracture in the tympanomastoid segment. No matter what the finding of the scan such a case should be discussed with an expert otoneurosurgeon. 13:552–555. 92. Traumatic perilymph fistula is discussed elsewhere. 1992. decompression of the horizontal and labyrinthine segments of the nerve and this requires otoneurosurgical input. If such a patient is seen soon after the injury and there is a clear history of an immediate and total lower motor neurone facial palsy. Should the leak persist a CT scan using intrathecal metrisamide may identify the site of the leak. The scan may have missed a bone splinter impinging on the nerve and waiting at least 14 days for nerve conduction studies may result in irreparable damage to the nerve. decompressing the tympanomastoid segment and the labyrinthine segment. It therefore follows that an otoneurosurgeon should be contacted if decompression of the nerve is contemplated. Electromyography will provide an indication of the severity of the injury and the prognosis in those patients where the history is not clear. this suggests a severe injury to the nerve (it may be caught in a fracture line or be compressed by a fracture. A policy of bed rest but sitting up to reduce intracranial CSF pressure and antibiotic cover to prevent intracranial infection usually allows resolution to occur after about ten days. American Journal of Otolaryngology. . the injury is likely to be secondary to a neuropraxia and a conservative policy should be adopted. A fracture of the labyrinthine segment requires. Hirsch BE. The decision therefore depends on the surgeon’s experience and expertise. as a minimum. 2 transferrin application in otology. CSF otorrhoea is confirmed by the presence of glucose and 2 transferrin.OTOLOGICAL ASPECTS OF HEAD INJURY 221 Management of a facial palsy following a head injury It is unusual for otolaryngologists to see a patient with a significant head injury soon after the injury as they will have been managed by neurosurgeons. with about 90% recovery to House and Brackmann grade I or II. If no fracture is seen on a CT scan many otoneurosurgeons would still advocate complete decompression of the nerve from the IAM to the stylomastoid foraman. The latter segment is important as it is in this region where the bony canal is narrowest and the nerve most susceptible to injury from oedema. usually from the middle fossa and allow exploration by an otoneurosurgeon. If the summating potential is more than 10% of normal after 14 days the prognosis is good. a bony spicule may be impinging on the nerve or there may be complete transection of the nerve). many otoneurosurgeons would advocate a complete decompression of the nerve from the internal auditory meatus to the stylomastoid foraman. p. 244. If it is less than 10% after 14 days then the consensus view is to explore the nerve. Kelly RH et al. Perilymph fistula. p. Others argue that a high quality scan is unlikely to miss a fracture and that exploring the nerve in such circumstances may further traumatize the nerve. In patients who develop a facial palsy hours or days after injury or in whom the palsy is partial. Further reading Bassiouny M.

1.OTORRHOEA Definition Otorrhoea is the discharge of material from the external auditory meatus. serous exudate or transudate. The middle-ear cleft is well endowed with mucous glands. The cardinal symptom of otitis externa is itchiness. trauma. In addition. they tend to provoke a hyperkeratosis. Chronic otitis media is not typically characterized by pain. when it will develop in about 5% of cases. Trapped keratin is offensive. neoplasm). it is wise to consider a carcinoma. Clinical features The character of the discharge depends on (and therefore gives clues to) its source. It is both a symptom and a sign. debris. Causes Otitis externa and active suppurative otitis media are the commonest diseases causing this problem. and CSF (usually following a fracture). In both cases the fluid may initially be mixed with blood and may be recognized by the halo sign in which there is a clear ring of moisture surrounding the blood after absorption on to blotting paper. blood (acute otitis media. 3. External ear. A serosanguinous discharge is common with chronic otitis media when the middle-ear mucosa has become granular and polypoid. Other causes include: wax. which may lead to bleeding from the ear. pain and tenderness. if there is a mucoid component to the discharge it usually arises from the middle ear via a perforation of the tympanic membrane. This is due to the faster diffusion of . It is not a diagnosis. The external canal may also be the subject of trauma. Blood stained discharge is also a feature of carcinoma of the middle ear. CSF rarely discharges from the ears spontaneously but may do so following skull base surgery or more commonly trauma. Middle ear. in addition to the discharge. so in patients where chronic otorrhoea becomes painful and fails to respond to the usual conservative measures. Acute inflammatory conditions of the external meatus therefore tend to produce a watery. There are no mucinous glands in the external canal. there is glandular hyperplasia and there may be blood as the mucosa bleeds easily. 2. This combination generally leads to soggy white debris collecting in the canal and a thin white watery discharge from the ear. Cerebrospinal fluid. Thus. if a cholesteatoma should become infected the discharge tends to be particularly unpleasant and once smelt is never forgotten.

Fluorescein injected by lumbar puncture may be helpful in finding the site of the leak at the time of surgery. the diagnosis is usually not made until the tympanic membrane has been visualized. conservative management is reasonable for the first few postoperative days but surgical repair will be required if the leak fails to settle. Related topics of interest Acute suppurative otitis media. This may not be possible at the initial consultation owing to swelling and debris in the external auditory meatus. Otitis externa. Further reading Applebaum EL. for instance. Post-traumatic leaks usually resolve spontaneously within a short period. vol. Otherwise it may pass down the Eustachian tube and become evident as rhinorrhoea or post-nasal drip. Any granulation type tissue removed should be sent for histology. Differentiation of CSF from thin serous discharge from a middle-ear cavity may be more difficult but can be done by estimation of the glucose content or by confirming the presence of 2transferrin in CSF. 35. 965–974. Head and Neck Surgery. Cholesteatoma. but surgical repair will be required if they continue beyond 14 days. The type and method of repair employed will depend on the site and cause of the leak and to some extent the state of the middle ear and the patient’s hearing. diagnosis of cause. latrogenic leaks should hopefully be recognized and repaired at the time of surgery. CSF leaks. Although the history will give many clues. If the tympanic membrane is intact CSF may still leak from the ear should there be a fracture in the roof of the ear canal. coughing. Management Optimum management depends on making an accurate diagnosis. The mainstay of therapy is aural toilet.g. p. 38. p. 1. If this is not the case. Middle-ear disease will demand treatment on its own merits. At the time of definitive diagnosis more appropriate treatment can be continued. This enables a thorough assessment. This will invariably require attention to the primary or secondary otitis externa by thorough aural toilet and possibly the insertion of a wick. St. it would be inappropriate to obliterate the middle ear of an individual with normal hearing. 2nd edn. This is best achieved with highresolution CT scanning and the subarachnoid injection of Omnopaque 500. ideally by microsuction clearance.OTORRHOEA 223 the less viscous CSF. Prior to any surgical exploration a thorough radiological assessment of the temporal bone should be undertaken to try to establish the site of the leak. Patients with CSF otorrhoea should be initially covered with prophylactic antibiotics to reduce the risk of meningitis. 218. and allows better penetration of any topical treatments. 1993. 209. straining). p. Conservative management includes sitting upright in bed and avoidance of manoeuvres that raise intracranial pressure (e. Otological aspects of head injury. p. A swab should be taken for culture and sensitivity (bacteria/fungi). In: Cummings CW et al. p. 5. (eds). This is especially important in patients who have already been on treatments which have not worked. . Otolaryngology. Louis: Mosby. Chow JM. Chronic suppurative otitis media. Treatment of the otitis externa will be sufficient if this is the diagnosis. Treatment will often commence on the basis of a best guess diagnosis.

Prevalence and incidence The clinical disease has been estimated to effect 0. The incidence of clinical disease (number of new cases per year) is much lower. the petrosquamous suture and in the cochlea. the round window. Eighty-five per cent of otosclerotics have bilateral disease. The three main theories of pathogenesis are: 1. It is an expression of humoral autoimmunity to type II collagen.0067%. 3. even if we were to assume every consultant performed eight stapedectomies per year.5–2% of the population (the prevalence) and the subclinical disease affects about 10% of the population. It is an expression of persistent measles virus infection of otic capsule-derived bone. the semicircular canals. . The incidence of otosclerosis is higher. but not all consultants perform stapedectomy. The average consultant/trainee team in the UK perform on average eight stapedectomies per year (range 0–30). 2. but will nowhere near approach the 1% incidence that is often quoted in major texts. canaliculi and marrow spaces. It is uncertain whether cochleovestibular symptoms arise directly from this encroachment or from factors released by the plaque or from both. would be approximately 4000 per 60 million or 0. lacunae. It is an expression of a genetic mutation in collagen metabolism which is only phenotypically expressed in bone derived from the otic capsule. Symptoms occur when these foci fix the stapedial footplate and encroach upon the labyrinth. Foci have also been noted in the region of the fissula post fenestram. Pathogenesis Otosclerotic foci are most commonly located just anterior to the oval window in the region of the fissula ante fenestram. The incidence of stapedectomy.05% as we would not expect all subjects with clinical otosclerosis to have a stapedectomy. the base of the styloid process.OTOSCLEROSIS Definition Otosclerosis is an autosomal dominant disease of incomplete penetrance affecting bone derived from the otic capsule in which mature lamellar bone is replaced by woven bone of greater cellularity and vascularity featuring large Haversian canals. perhaps 0.

Congenital foot plate fixation. perhaps because women are more likely to seek advice because pregnancy. Masked air conduction typically shows a loss which is greater at low frequencies when there is minimal cochlear impairment but the frequency response curve flattens and then shows a predominantly high frequency loss as cochlear impairment progresses. . 2. No major randomized prospective double blind trial has been performed to assess its effectiveness. Mild and usually transient.OTOSCLEROSIS 225 Otosclerosis is more common in Caucasians. Sodium fluoride. Management 1. 2. Its use remains controversial. Osteogenesis imperfecta. Tinnitus. Clinical features The main symptoms are: 1. and on the cochlear reserve. Ten per cent of ears display Schwartze’s sign. Vertigo. Rinne’s test usually suggests a conductive hearing loss. Speech audiometry. A female: male ratio of 2:1 has been noted. Crural atrophy. Better hearing in noisy surroundings is often described—paracusis Willisi. Deafness. Women are more likely to have bilateral clinical disease. Investigations 1. A hearing aid. 3. Paget’s disease (usually produces a mixed hearing loss). Symptoms may mimic benign paroxysmal positional vertigo. The masked bone conduction curve typically shows a dip at 2000 Hz which may be small or exaggerated particularly when there is only a slight cochlear loss (Carhart’s notch). In addition to a conductive hearing loss there may be cochlear impairment. Congenital cholesteatoma. The curve shows a predominately high tone loss when there is severe cochlear impairment. Differential diagnosis • • • • • • • • Fibro-osseous foot plate fixation. 3. menstruation and the menopause may cause the disease to progress rapidly. It causes no other otoscopic signs. Fixed malleous-incus syndrome. Ossicular discontinuity. Present in 75% of patients especially when there is a cochlear element to the deafness. 2. Pure tone audiometry (PTA). The Weber may be referred to either ear depending on whether disease is unilateral or bilateral. Noticed in most cases before the age of thirty. With amplification the score approaches one hundred with normal cochlear function but the score falls according to the severity of the cochlear loss. Impedance audiometry. a pink tinge of the tympanic membrane imparted from dilated blood vessels on the mucous membrane of the promontory. Unreliable as a diagnostic aid although it may be useful in selecting the more suitable ear for surgery in bilateral otosclerosis with a symmetrical PTA by suggesting the more rigid stapes.

The smaller the fenestra. • Avoid flying for the first three weeks post-operatively. Complications of stapedectomy 1. The incidence reported by expert otologists varies from less than 1–4% and a further 10% may have no better or worse hearing than pre-operatively. lifting heavy objects and aggressive nose blowing. The minimum requirements are at least a 15 dB conductive hearing loss with 60% speech discrimination. Stapedectomy. A micro drill. • • • • • Tympanic membrane tear. A 0. the smaller the risk of a high tone cochlear hearing loss. Second ear stapedectomy is still controversial but is advocated by many who perform the small fenestra procedure. 8 mm fenestra over which a vein graft is placed and a 0. • Tinnitus may not improve and may be more intense after surgery. Preoperative counselling • A hearing aid is an alternative method of treatment.4 mm prosthesis are popular. Technique 1. The ear including the external ear canal should be dry. a stapedotomy needle. • Taste may alter or be lost on one side of the tongue (damage to chorda tympani). The Causse technique comprises a 0.4 mm prosthesis. Large fenestra. An attempt is usually made to seal the oval window with a vein or fat graft prior to prosthesis insertion. • A dead ear may occur with stapedectomy. Small fenestra. Tympanosclerosis arthrodesing the incudostapedial joint. The otologist aims to get complete or over-closure of the air bone gap. Over-closure is possible because of the Carhart effect and is greatest at 2000 Hz (see audiometry chapter). Overhanging facial nerve. Postoperative advice • Avoid diving when swimming. Persistent stapedial artery. or an argon or KTP laser is used to create the fenestra in the stapes footplate. .226 OTOLARYNGOLOGY 3. • Vertigo may be present immediately postoperatively and in a minority there may be a permanent sense of imbalance. A portion of the footplate is removed with picks and fine right angle hooks. Chorda injury.6 mm fenestra drill piece and 0. • There is a very small chance that the facial nerve will run an anomalous course either splitting around or coursing inferior to the oval window and may be injured. • Open the mouth on coughing or sneezing. If both ears are suitable for surgery in bilateral disease the poorer hearing ear should be chosen. It is contraindicated in pregnancy. 2. Peroperative.

OTOSCLEROSIS 227 • • • • Perilymph flooding. Revision stapedectomy There are three main groups who should be considered for revision stapedectomy: (a) Patients who have redeveloped a conductive hearing loss after stapedectomy. (b) Patients who have had no closure of the air-bone gap following stapedectomy. 2. It may be the cause of a dead ear from an apparently uncomplicated procedure. This lies as close as 0. An immediate dead ear may occur if too long a prosthesis injures the saccule. . particularly if associated with loud noises or with applying pressure to the external ear canal. The commonest causes of a persistent conductive hearing loss are a dislocated prosthesis. Depressed footplate. Injury to the saccule. An immediate dead ear may arise from the footplate problems noted above. Floating footplate. Displacement of prosthesis from oval window. Early. A high definition CT scan may detect an otosclerotic plaque. • Secondary perilymph fistula. Loose attachment of incus and prosthesis. • • • • • Detachment of prosthesis from incus. (c) If vertigo persists or develops several weeks after stapedectomy. It is easily disturbed when performing the stapedotomy or inserting the prosthesis.4 mm beneath the footplate. This is due to too long a prosthesis irritating the saccule. a prosthesis which is too short or a dislocated malleo-incudal joint. Persisting primary perilymph fistula. 3. or erosion of the long process of the incus due to pressure necrosis from the loop of the prosthesis. Look for Schwartze’s sign on otoscopy. Cochlear otosclerosis Consider when there is a family history of otosclerosis and progressive sensorineural hearing loss in early adult life of no apparent cause. probably because of injury to the saccule with each of these events. but is usually 1–2 mm beneath. Footplate granuloma. The commonest causes are a dislocated prosthesis (from either the oval window or from the incus). • Necrosis of the long process of the incus. Late. • Late detachment or displacement of the prosthesis.

134. Gaeng D et al. HNO. Laryngoscope. Han WW. 244. Laryngoscope. 40: 476–479. Related topics of interest Labyrinthitis. Scheer AA. 301. 1992. Revision stapedectomy: intraoperative findings. Speech audiometry. 107:1185–1192. Gerber HA. Perilymph fistula.7 to 20%. Incesulu A. A review of 308 cases of revision stapedectomy. 1998. 108: 1794–1800. p. McKenna MJ et al. . Fishman A. Hammerschlag PE. 1997. Reported post-operative sensorineural loss in a number of series varies from 0. Further reading Altermatt HJ. p. Immunohistochemical findings in otosclerotic lesions.228 OTOLARYNGOLOGY The overall results of revision surgery are not as good as primary surgery. p. results and review of the literature.

particularly at the basal turn of the cochlea and to spiral ganglion neurons occurs with cochleotoxicity. Mitochondrial DNA is inherited maternally because the tiny amount of cytoplasm in spermatozoa cannot transmit mitochondrial DNA. Findings in animals suggest an elimination half-life of 6 months within the outer hair cells. the latter the number of free methylamine groups (-NHCH3). . Aminoglycosides cause mitochondrial dysfunction in susceptible patients so that there is inhibition of translation or mistranslation of mitochondrial protein synthesis. It is not X-linked but can be explained by mitochondrial inheritance. cochlea or the vestibulocochlear nerve. This in turn causes a reduction in intracellular adenosine triphosphate (ATP) production with a resultant toxic accumulation of ions such as calcium and potassium within the cytoplasm and ultimately cell death.g. This may explain the cumulative ototoxic effects of aminoglycosides and why some patients develop ototoxicity only after a prolonged course or repeated courses of aminoglycosides. Electron microscopy confirms that injury to the first row of the outer hair cells. the ampullary cristae and the maculae of the saccule and utricle.g. The concentration in the endolymph therefore depends on the ratio of secretion to resorption which in turn depends on the drug’s serum concentration.OTOTOXICITY Ototoxicity is the partial or total reduction in cochleovestibular function caused by the interaction of chemicals. Aminoglycosides All aminoglycoside antibiotics have a tendency to be predominantly either cochleotoxic (e. The former relates to the number of free amino groups (-NH2). Light microscopy shows destruction of the sensory cells of the organ of Corti. with the vestibule. gentamicin and tobramycin). Resorption by the stria clears the endolymph of aminoglycoside. Geneticists have found that susceptibility to aminoglycoside ototoxicity is transmitted exclusively by women. Mechanism of action Current opinion holds that secretion of aminoglycoside from the stria vascularis into the endolymph and perhaps from the vessels of the spiral ligament into the perilymph occurs with active uptake of antibiotic from the perilymph into the endolymph. commonly therapeutic agents. It is important to note the damage to the vestibular and cochlea sensory cells is greatly enhanced by the synchronous use of a loop diuretic. neomycin and kanamycin) or vestibulotoxic (e. There are over 200 ototoxic substances but only a small group of drugs in common therapeutic use are regularly associated with ototoxicity.

Nystagmus may not be demonstrable but caloric testing shows a bilateral decline in labyrinthine function. Preloading with glutathione and vitamin C may become standard practice to minimize ototoxicity. Investigations Monitoring of patients taking these antibiotics by regular inquiring of otological symptoms and by the regular measurement of serum peak and trough levels are necessary to reduce the incidence of ototoxicity and to allow early withdrawal of therapy should they arise. presenting some days into treatment and is usually progressive.3dihydroxybenzoate reduce gentamicin ototoxicity in guinea pigs in vivo and iron chelators may have a clinical role to play in reducing aminoglycoside ototoxicity in the future. It may become more intense and persistent in spite of drug withdrawal. Neurotrophins such as brain-derived neurotrophic factor protect the spiral ganglion neurons but do not prevent outer hair cell degeneration. uncertain. Clinical features 1. Hypoproteinaemia also increases the chances of cytotoxicity but this can be overcome by administering large doses of glutathione with vitamin C. a large total dose (in gentamicin’s case >1 g) and a subject aged over 60 all increase the chances of ototoxicity. Loop diuretics Frusemide. A permanent hearing loss is unusual but has been described in renal dialysis and transplant patients. in many cases. 2. Vertigo is characteristically a bobbing oscillopsia whereby distant objects appear to jump about on head movement. Cytotoxic agents Cisplatin is the most important drug in this group as for many it is the drug of choice in palliating head and neck cancer. It is of note that two iron chelators. Gentamicin in the presence of iron salts produces peroxidation of arachidonic acid in vitro so aminoglycoside ototoxicity may be caused by free radical formation in the presence of iron salts. Withdrawing therapy may prevent further significant deterioration provided renal function is adequate. The mechanism is thought to be that antioxidants prevent aminoglycosides being converted enzymatically within the cell to a cytotoxin that causes mitochondrial dysfunction. It and nitrogen mustard have a similar cochleotoxic effect to the aminoglycosides in causing greatest injury to the first row of outer hair cells particularly at the basal turn of the cochlea but inner hair . desferoxamine and 2. Tinnitus may occur during or after withdrawing treatment. Hearing loss is principally high frequency and sensorineural. bumetamide and ethacrynic acid in high doses may produce a reversible high tone sensorineural hearing loss. 3.230 OTOLARYNGOLOGY Studies with preloading antioxidants (in particular glutathione and vitamin C) prior to aminoglycoside exposure have shown a significant protective effect. Since 5% of this group become deaf purely as a result of their disease the contribution of the diuretic to the deafness is. A pyrexia. Aminoglycosides are excreted by the kidney and the administered dose must be reduced in renal failure. Light microscopy shows the stria vascularis to be grossly oedematous but the organ of Corti remains essentially normal.

g. The vertigo may be either acute and reversible on withdrawing treatment or more commonly chronic. omeprazole to prevent upper GI complications. In vivo studies in humans have suggested that preloading with diethyldithiocarbamate and an agent known only as WR2721 prior to cisplatin delivery significantly reduces not only ototoxicity but also toxic effects on the gastrointestinal tract. In those where phenytoin must be used to control the disorder careful monitoring of the serum levels are necessary. As most of the drug is bound to plasma proteins. In a minority. cimetidine or a proton pump inhibitor e. There is degeneration of spiral ganglion neurons. bone marrow and kidney. Salicylates Aspirin in overdose may induce tinnitus and a flat pure tone hearing loss of up to 60 dB. particularly towards the apex. This is usually reversible on withdrawing the drug. e.and post-dose audiometry is necessary to monitor cochleotoxicity which may be partially reversible on withdrawal of treatment. Quinine Formerly used in the treatment of malaria and still used today to control night leg cramps.g. hypersensitivity occurs whereby cochleotoxicity develops at therapeutic plasma levels. These ototoxic effects are potentiated by hypoproteinaemia and anaemia. Ongoing studies are taking place to confirm this and also to demonstrate whether the agent affects the tumouricidal effects of cisplatin.OTOTOXICITY 231 cells are also injured. Anticonvulsants Vestibulotoxicity has been described with phenytoin and ethosuximide. Aspirin is cleared rapidly by the kidney so that treatment comprises adequate hydration and the use of an H2 antagonist e. the conductive element being secondary to a middle ear effusion. The cochleotoxic effects are generally mild and reversible. . minimize morbidity and may aid symptomatic recovery by accelerating compensation. Pre. Aftercare and follow-up Cochleotoxic symptoms require regular pure tone audiometric monitoring until thresholds are stable or improve (temporary threshold shift) in order to quantify the disability. plasmaphoresis is an effective therapy in massive overdose.g. Vestibulosedative medication and rehabilitation exercises. quinine has cochleotoxic effects similar to aspirin except hearing loss may progress after withdrawing therapy and is more likely to be permanent. Cooksey-Cawthorne exercises. and degeneration of the stria vascularis. Vestibulotoxic recovery can be symptomatically monitored by out-patient assessment and if necessary quantified by ENG caloric measurements. The vestibular apparatus is undisturbed and recent work has suggested a direct effect of salicylates on the outer hair cells of the cochlea. The pathogenesis of both the cochleotoxicity and the effusion is unknown. Beta blockers A mixed deafness has been described.

Somani S. p. p. Hearing Research. McLaren J. Variable efficacy of radical scavengers and iron chelators to attenuate gentamicin ototoxicity in guinea pigs in vivo. Song B. 1995. Vertigo. Schacht J. Hearing Research. Tinnitus. Lautermann J. Related topics of interest Sudden hearing loss. 314. Glutathione protection against gentamicin ototoxicity depends on nutritional status.232 OTOLARYNGOLOGY Further reading Rybak LP. 94:87–93. Caloric tests. 1996. Ravi R. 26:293–300. . 327. p. Schacht J. 27. 1995. p. 346. 86:15–24. Mechanism of protection by diethyldithiocarbamate against cisplatin ototoxicity: antioxidant system. Fundamentals of Applied Toxicology.

although if high in the trachea it may be ‘biphasic’. but this topic confines itself to the following conditions: • • • • • • Laryngotracheobronchitis. Wheezing is the province of the respiratory physician and will not be discussed here. Children with Down’s syndrome and . webs. Choanal stenosis. gastro-oesophageal reflux). Noisy breathing from the chest is usually expiratory. Problems will nearly always produce noisy breathing (stridor/stertor) or affect the voice (hoarseness). Miscellaneous conditions (papillomata. cysts. Laryngomalacia. enlarged adenoids (or tonsils). There are many diseases which can cause paediatric airway problems. Subglottic stenosis. is known as wheezing and is the result of an asthma-like condition. A laryngeal lesion is usually characterized by inspiratory stridor and a tracheal lesion by expiratory stridor.PAEDIATRIC AIRWAY PROBLEMS Introduction Paediatric airway problems are different from adult problems because congenital abnormalities manifest themselves early in life and the airway is significantly narrower. Bilateral choanal atresia can cause such symptoms but there are other more serious problems in this condition and surgical relief is provided as a matter of urgency. Any factor which reduces the size of the lumen will therefore have a greater effect in the neonate and child. rhinitis and muscular incoordination can all be responsible and each condition should be treated on its merits. and individual conditions are best discussed through these symptoms. Vascular ring. Noise from the neck region is known as stridor and is caused by narrowing of the respiratory lumen in the upper trachea or larynx. It may be expiratory or inspiratory. Vocal fold paralysis. Stertor Stertor is noise originating from the back of the mouth or nose. the neck or the mouth and nose. Stridor Abnormal noise during breathing may emanate from the chest.

It may only be slight and present in certain positions. The commonest cause of persistent hoarseness is the presence of vocal nodules. If further deterioration occurs. The condition follows a self-limiting course. but at worst there would be recession of the chest and suprasternal region and interference with feeding. The insertion of a nasopharyngeal tube which projects just beyond the soft palate is helpful in most refractory cases. the surplus lax mucosa can be excised from the superior border of the aryepiglottic fold under the microscope or a laser aryepiglottoplasty can be performed. if considered. if symptoms are marked. Epiglottitis produces more severe symptoms which are discussed elsewhere. Tracheostomy is virtually unknown for laryngomalacia and. The usual finding is a relatively narrow subglottis which will widen with growth. On those unusual occasions when extubation is not possible a tracheostomy will be necessary. As the condition improves a leak appears around the tube and the child is extubated. . and many patients can be treated at home with antibiotics and humidity in the form of steam. dexamethasone and sometimes an adrenaline nebulizer. Removal with the laser is only indicated when they are large. Laryngo-tracheo-bronchitis This is a very common cause of stridor. and they appear more quickly and clear equally rapidly. but they do respond to speech therapy. antibiotics. If the symptoms get worse. The inspiratory stridor accompanied by a harsh cough will usually follow a throat infection. Allergic oedema produces similar symptoms. oxygen. Since the diameter of the subglottis in the normal population follows a normal distribution curve.234 OTOLARYNGOLOGY cerebral palsy are particularly prone to trouble. where the airway in the child is narrowest and the submucosal tissue lax. Laryngomalacia This condition may appear within an hour or two of birth and is the commonest cause of stridor in infants. and most of the milder cases will not reach the hospital. It is temporary in laryngitis and is the presenting symptom with papillomata. it is self-evident that those who have a small glottis initially will be more affected. nothing need to be done apart from a 3-monthly follow-up with advice to return in the interim if symptoms worsen. The symptoms gradually improve with time but may take several years to stop. If severe or if there is parental anxiety. admission to hospital. It is characterized by an intermittent stridulous squeak of varying severity. These are unlikely to be caused by misuse of the voice as they have been described in the neonate. Endoscopy should be avoided in the acute period (as it increases oedema) but should be done to identify an underlying abnormality if attacks recur. This is best done by a paediatric intensivist or anaesthetist and as small a tube as possible is used. an associated vocal cord palsy should be suspected and excluded. intubation is carried out. The child is closely observed after treatment with humidity. If slight and parental anxiety is absent. Infective oedema will narrow the lumen. particularly in the subglottic area. a direct laryngoscopy is carried out. becomes necessary. Unilateral vocal cord palsy can also produce a weak or hoarse voice and is seen following cardiac operations. It is due to an indrawing of floppy supraglottic structures (particularly the arytenoids and aryepiglottic folds) during inspiration. preferably to an intensive therapy unit. The diagnosis is confirmed and. Hoarseness Hoarseness indicates an abnormality of the vocal cord.

In many cases the cause is unknown. as most will recover within 2–3 years. A large tube predisposes to stenosis. An attempt should be made to treat the condition conservatively. a tracheostomy becomes necessary. If there is total stenosis or if a pin-hole lumen persists. It may be impossible to extubate the infant. although this is best left until the age of 2 years. Splitting of the cricoid and upper trachea with insertion of costal cartilage into the split is the standard surgical approach. In order to exclude the diagnosis. wide abduction of the cords must be seen. The baby should be seen at regular intervals and the movement reassessed every 6 months. More commonly it is necessary to perform direct laryngoscopy with the baby anaesthetized but maintaining vocal cord function. The parents will require support and must have easy access to the hospital if they are worried. sometimes a progressive stridor develops weeks or months after extubation.PAEDIATRIC AIRWAY PROBLEMS 235 Vocal cord paralysis A unilateral vocal cord paralysis will usually produce no symptoms apart from some weakness of the voice. In some cases the stridor is so bad and indrawing so severe that tracheostomy is the only treatment. . The diagnosis is made by laryngoscopy and it is sometimes possible to see the larynx in the awake patient with a transnasal fibreoptic endoscope. If extubation is impossible. the child can be left until there is an adequate airway and then decannulated. and in the neonate prolonged intubation associated with prematurity is the usual cause. Adduction and passive movements of the cords with respiration can easily be mistaken for normal function and there are occasions when a diagnosis cannot be made with certainty. however. but an anterior split will suffice in milder cases. with vocal cord paralysis the symptoms and signs become worse with time as the baby makes stronger inspiratory effort. The stridor of laryngo-tracheitis is due to temporary oedematous stenosis and a relatively small cricoid ring may first manifest itself with these symptoms. the cricoid can be split in the neonate and a temporary stent inserted. and any additional narrowing due to oedema or scar tissue will tend to cause stridor. but this is not mandatory. may need to be repeated before an adequate airway and decannulation is achieved. The cry is usually normal as adduction is not affected. This operation. Decannualation should occur as soon as normal function returns. however. More often. A stent is usually introduced for a few weeks. The decision to treat the vocal cord surgically should be left for several years and should be made only after thorough and informed consultation with the child and parents. but a bilateral vocal cord paralysis produces a stridor which is very similar to that found with laryngomalacia. The most severe cases. although a significant number have other abnormalities. It is useful to reach a consensus by inviting the anaesthetist and any available surgeon present to make an assessment as there is a considerable subjective element. known as laryngotracheoplasty. The size of the subglottis is then assessed under general anaesthesia every few months by passing endotracheal tubes until a snug fit is obtained. surgery is necessary. If the lumen is obviously enlarging. follow trauma. However. More severe cases will require an anterior and posterior split. but a constitutional tendency to fibrosis is the only explanation for those who develop stenosis after only 2 or 3 days of small tube intubation. Subglottic stenosis The subglottis is the narrowest portion of the paediatric airway.

There is little to be gained from consideration of the vascular abnormalities as these are complex and often confusing to the chest surgeons themselves. Endoscopy will show a pulsatile narrowing of the trachea and correction is carried out by the chest surgeons. 4. p. reflux oesophagitis needs to be excluded by investigation. Miscellaneous Numerous lesions in the laryngeal region will encroach upon the airway and cause stridor. 138. a tracheostomy may become necessary. Every neonate with no obvious cause for the stridor should therefore have a barium swallow. 1.236 OTOLARYNGOLOGY Vascular ring Abnormal blood vessels in the chest may compress the trachea and oesophagus and classically produce an inspiratory and expiratory stridor associated with feeding difficulties. 5. but in the interim laser removal is required and certain individuals do not develop immunity. If very virulent and florid. p. 3. . A conservative approach can often be taken as many lesions involute as the infant grows. Paediatric endoscopy. Related topics of interest Epiglottitis. Reflux has been implicated in the cause and exacerbation of laryngo-tracheal stenosis and if there is evidence that effective management of reflux improves the primary pathology of even laryngeal papillomatosis. 2. p. Cysts. 336. 237. but the laser has made early removal possible. 70. Cysts can also be aspirated and sometimes removed. which is believed to be caused by softening of the tracheal rings by the pulsatile vessel. as in the Pierre-Robin syndrome. Nursing in the prone position is helpful. Micrognathia or a large tongue can narrow the upper airway. 311. but reconstructive surgery with stenting can be necessary. but even a tracheostomy is considered in the worse cases. Hoarseness and airway problems occur as a result of scarring and can require reconstructive surgery. Gastro-oesophageal reflux is widely accepted as an important factor in all sorts of paediatric airway problems. If they are small and only produce minimal symptoms they are best left alone. Larger webs may be opened with the laser. As many as 80% of laryngomalacia babies are said to have reflux and it is suggested that these be treated empirically with antireflux medication. Even after correction there may still be narrowing due to tracheomalacia. Tracheostomy. They usually disappear when immunity develops. which will demonstrate the oesophageal narrowing. Subglottic haemangioma is the most common neoplasm of the infant airway. Where there is no obvious anatomical cause for stridor. Laryngeal webs may be congenital or acquired. p. Laryngeal carcinoma. p. Papillomata are viral warts which vary greatly in virulence. Stridor and stertor. haemangiomata and lymphangiomata can occur in the subglottis and less often in the glottis and supraglottis.

When a tracheoscopy or bronchoscopy is also to be performed. For the purpose of identifying a lesion in the glottis or subglottis. Laryngoscopy Adult laryngoscopes such as the Kleinsasser range can be safely used for children. postnasal space and larynx can be done in the child or infant. These are excellent for teaching purposes. Paediatric oesophagoscopy is also commonly performed by the paediatric surgeon. the tip of the laryngoscope is passed posteriorly to the epiglottis as this structure may obstruct the view. Subglottic stenosis is identified on laryngoscopy if the vocal cords are not in spasm. In most cases. oropharynx and mouth are examined with . but this is withdrawn into the hypopharynx during laryngoscopy and the patient breathes spontaneously. If vocal cord movement or laryngomalacia is being assessed. the tip of the laryngoscope is best placed in the vallecula to avoid fixation of the glottic and supraglottic structures. although subsequent treatment is often the province of the chest surgeon. it is best to watch glottic and supraglottic movement at the end of the procedure while the patient is regaining consciousness and producing more movement. clinical record and follow-up comparisons. An endotracheal tube is in place for the induction of anaesthesia.PAEDIATRIC ENDOSCOPY Endoscopy of the respiratory tract is commonly carried out by the otolaryngologist. paediatric endoscopy is indicated to provide a diagnosis in the presence of hoarseness and stridor. physician or anaesthetist. It is important that the lower lip is not pinched between the instrument and the teeth (or gums) and the upper teeth should be protected. and the smaller ones can even be used for neonates. Laryngomalacia is easily distinguished by the indrawing of the arytenoids. The fibreoptic endoscope can be passed through the nose or through a laryngeal mask and the latter procedure is very useful in the diagnosis of vocal cord paralysis. but it can be difficult owing to lack of cooperation in the awake patient. A wide abduction of the cords must be seen before normal cord movement is diagnosed. Endoscopy is best avoided within a week following infection and oedema should first be allowed to subside. This gives a better view and suction is available. As large a size as possible is advantageous in order to obtain the widest view of the larynx. the hypopharynx. Essentially. There is an increasing use of Hopkin rod telescopes with video and still documentation facilities. Fibreoptic examination of the nose. paediatric endoscopy involves the use of a rigid laryngoscope or bronchoscope (with a telescope incorporated). Where a full examination of the respiratory tract is required. but normal vocal cord movement is more difficult to identify.

238 OTOLARYNGOLOGY the laryngoscope at the same time and both oesophagoscopy and examination under anaesthetic of the nose may be indicated. 232. 336. The main bronchus should be entered. but it is often possible to pass the bronchoscope past the tube. p. If not. This may not be possible if there is a high subglottic stenosis. Bronchoscopy A rigid telescope and bronchoscope of suitable size is introduced into the larynx with the help of McGill’s anaesthetic laryngoscope. An inability to see the carina when the lumen is apparently clear should raise suspicions of a vascular ring. If there is a tracheostomy present. suprastomal granulations will nearly always be seen. Tracheostomy. In the normal patient the carina can be seen as soon as the instrument passes through the glottis. During the removal of the endoscope the surgeon should continue to visualize the respiratory tract as damage is avoided and rarely a lesion is seen which had previously been missed. p. and anaesthesia is then administered via the laryngoscope. Related topics of interest Laryngeal carcinoma. tracheomalacia or some other source of extrinsic pressure. p. Stridor and stertor. . 138. Paediatric airway problems. but more extensive investigation of the bronchial tree is necessary if a foreign body is suspected. the tube is removed. The bronchoscope is passed down to the carina with examination of the walls to exclude a tracheo-oesophageal fistula. p. The vocal cords are examined before passing the instrument gently through the glottis. 311.

which will help facilitate the development of speech and communication.PAEDIATRIC HEARING ASSESSMENT The assessment of hearing in children demands a variety of approaches which vary with the age of the child. Screening tests Hearing is important for normal speech development. This will allow the provision of suitable support and aids. Neonatal: Universal screening (OAEs with BERA if indicated). 2–4 years and again shortly after school entry. parental concern. 0. Behavioural techniques (0–6 months). The best results are achieved in multidisciplinary paediatric assessment centres where the environment and organization are geared for children. as will any child who persistently fails a screening test at any stage. at 7 months. 7 months: distraction test (see below). Recent evidence has suggested that waiting until 7 months of age for a first screening test is too late. and it is important that moderate and severe hearing losses are diagnosed early. post meningitis. This involves otoacoustic emission testing shortly after birth (the failure rate is reduced by waiting until after 48 hours of age).1% of live-born babies will have a severe hearing impairment. Some experience is needed in interpreting the variety of possible . Listed below are the current screening methods of choice for the various age groups at which testing occurs. 2–4 years: distraction tests or conditioned response audiometry. intensive care units (1–2% will have a severe hearing loss). children may be referred for assessment from other sources because of concern about their hearing. 2.g. e. Most health authorities maintain an at-risk register of families in whom possible prenatal and perinatal causes exist. 5 years and over: pure tone audiometry. 4. Subjective hearing tests 1. Any failures are then subject to automated brainstem evoked audiometry. Screening tests. children in the UK have been subject to regular screening tests. 3. This method is based on the presentation of a loud sound and observation of the baby’s response. The choice of test will depend on the child’s age. So called ‘Universal neonatal screening’ has therefore been proposed as a better solution. Nearly all subjective testing will require two testers. A thorough history from the parent or regular carer and a clinical examination are essential parts of the assessment. family history. intellect and motor abilities. subjective hearing tests and objective tests are all available. 1. In addition. Children failing both tests are referred for a more thorough audiological assessment. In an effort to achieve this aim.

With the child sitting comfortably on his or her mother’s lap. a flashing light) to reinforce the turning response. The child sits in an acoustic room at a table (usually with a parent) and is allowed to play with some toys. Otoacoustic emissions (0–12 months). These tests involve asking the child to point to or handle a variety of toys. Auditory response cradle (0–6 months). 3. Much of the recent work with otoacoustic emissions is related to their feasibility as a screening tool for sensory hearing loss. This technique may also be used with older children to obtain a pure tone audiogram. If the child turns to the correct speaker at signal presentation a visual (reinforcing) stimulus is presented adjacent to the speaker (e. This technique is discussed in detail elsewhere (pure tone audiometry). behind and to one side of the child. 2. Sounds (warbles or pure tones) are produced from one of two loudspeakers placed at 30° either side of the child. after hearing a specific auditory stimulus. A microprocessor analyses the responses to the sound stimuli. The stimulus is 5-second bursts of 85 dB sound pressure level (SPL) sound made into earphones. The use of evoked otoacoustic emissions has been recommended as a mainstay of universal screening programmes. Evoked response audiometry. sibilant s for higher frequency or a high-frequency rattle in younger children. A positive response is one in which there is a significant alteration in activity. which include startle. 3. In essence it is a free-field audiogram. Respiratory changes are monitored by a transducer in a band around the baby’s chest. and makes an objective verdict of pass or fail. Distraction techniques (6–18 months). Speech discrimination tests (24–60 months). In the McCormick toy test there are seven pairs with names that are acoustically very similar. e. Most children of around 5 years can with a little encouragement be persuaded to perform an audiogram. The procedure is repeated on both sides. Conditioned reflex (performance testing) audiology (24–60 months). Visual reinforcement audiometry (9–36 months). 4. A positive response is when the child turns to the sound. blinking. Head turning. startle responses and body movements are recorded by pressure transducers in the head rest and mattress. even if only at three frequencies in each ear.g. key/ tree. 5. With this method it is important to avoid any visual cues. The tester then distracts the child by making sounds of various intensity. Distortion-product otoacoustic emissions have been shown to be particularly effective at 4 and 8 kHz. The toys are selected so that their names cover a range of speech patterns.240 OTOLARYNGOLOGY responses. or if the child is too young for conventional testing and there are doubts . In this way a reasonably accurate free field audiogram may be obtained. This device monitors four behavioural responses to the production of sound.g. taking account of the baby’s overall level of arousal. crying or the cessation of activity. 2. A handheld audiometer may be used with older children. cup/duck. The tester sits outside the test room and observes the procedure through a one-way mirror. This area of testing has been largely superseded by otoacoustic emissions. Test sounds include conversational voice for low frequency. Pure tone audiogram (60 months+). This technique involves training the child to perform a specific task such as putting a marble in a cup. This technique is relatively uncommon in the UK but more frequently used in USA and Australia. Objective hearing tests 1. This is indicated if there is any difficulty or uncertainty in the results of conventional distraction techniques. or giving a toy to the mother. without giving any visual cues. The stimulus may be the spoken word or a tone produced by a handheld audiometer. 6. Only those toys that are recognized by the child are used and the aim is to establish the speech level that gives an 80% correct response rate. an assistant attracts the attention of the child.

216. p. Its use is also suggested for neonatal screening in infants failing an OAE screen. Pure tone audiogram. Current Opinion in Otolaryngology and Head and Neck Surgery. p. p. Otoacoustic emissions. Universal newborn hearing screening programs. Related topics of interest Evoked response audiometry. 128. p. 6:346–351. 1992. Impedance audiometry. 1998. 254. 78. London: Whurr. .PAEDIATRIC HEARING ASSESSMENT 241 as to the child’s hearing ability. Further reading McCormick B. Paediatric Audiology 0–5 Years. Culpepper B.

which may become activated to form a recurrent lesion. where there is increased airflow. Electron microscopy and immunofluorescent techniques have shown that human papillomavirus DNA is incorporated into the host’s cellular DNA. Respiratory obstruction and increasing stridor are late manifestations of the disease process. They can be sessile or pedunculated and are characteristically non-keratinizing with a connective tissue core. The lesions have a predilection for points of airway constriction. Laryngeal mucus is thought to behave as a protective blanket in some sites. Polymerase chain reaction is now the most sensitive technique available to show evidence of HPV infection. but the vocal cords. They may grow anywhere in the respiratory tract from the lips to the lungs. for example the interarytenoid area. Apparently normal mucosa cells adjacent to the papillomas also contain viral DNA. crusting and irritation. obtain tissue for confirmatory histology and to assess the extent of the disease and potential risk to the patient’s airway. . anterior commissure and vestibular folds are the commonest sites of involvement.PAPILLOMA OF THE LARYNX Squamous cell papilloma is by far the commonest benign tumour of the larynx. Clinical features Hoarseness of voice or an abnormal cry is the usual presenting symptom. Adenomas. drying. fibromas. Treatment can also then be initiated. Investigations Endoscopy is required to establish the diagnosis. It is thought that in some patients the disease is transmitted at the time of delivery from a mother infected with genital warts. particularly HPV types 6 and 11. haemangiomas and other neurogenic and mesodermal benign tumours are all rare and will not be considered further. Pathology Squamous papillomas usually occur at any age from birth to 5 years. chondromas. Aetiology The aetiology of laryngeal papillomas is now known to be infection of the epithelial cells with human papillomavirus (HPV). This partly explains the difficulty in curing the disease. The growths may present as scattered single lesions or clusters or as a huge exuberant mass.

. Surgery is the most satisfactory treatment of this condition. 2. two operations 4 weeks apart are required to avoid web formation. New England Journal of Medicine. If disease is found to involve the anterior commissure. Mounts P et al Long term response of recurrent respiratory papillomatosis to treatment with lymphoblastoid interferon alpha-nl. Radiotherapy was used in the past. treating first one cord then the other. It is most likely to occur if the disease presents between the ages of 6 and 10 years and if the disease is confined to the larynx. Pilot trial of ribavirin for the treatment of laryngeal papillomatosis. 15: 504–513. Head and Neck. 1987. but further trials are required to substantiate this. Terry RM et al.e. Further reading Eicher SA. Single papilloma Single papillomas are usually seen in adults. and repetition of this procedure at intervals. 1. Because of treatment side-effects and uncertain response these treatments should be reserved for cases requiring frequent (i. to maintain a safe patent airway and laryngeal function. Donovan DT. Isotretinoin (13-cis-retinoic acid) produces a significant response in about two-thirds of patients. without damaging the larynx in the process. Tracheostomy should be avoided if possible as the papillomas can become implanted into the trachea and bronchi. McGlennen RC et al. Demonstration of human papillomavirus types 6 and 11 in juvenile laryngeal papillometosis by in situ hybridisation. Second Consensus. The treatment of choice is the removal of all the lesions using a laser. It is liable to recurrence and malignant degeneration. Taylor-Cooley LD. 1994. The papilloma should be removed at direct laryngoscopy. It has been claimed that the antiviral drug ribavirin is a useful adjuvant to surgery.PAPILLOMA OF THE LARYNX 243 Treatment The aim of treatment is to remove the papillomas as they appear. Head and Neck Surgeons. Follow-up and aftercare Laser laryngoscopy is repeated as often as necessary to preserve the airway and the voice in those cases which do recur. Journal of Pathology. Medical treatment Alpha interferon has been shown to significantly reduce the growth rate of papillomas in one-third of patients. Archives of Otolaryngology and Head and Neck Surgery. 1993. or if the trachea and bronchi become involved. 153:245–248. but should be avoided as it predisposes to malignant change. 120:405–409. Effective Head and Neck Cancer Management. The patients should be followed up for 5 years because of the risk of recurrence and malignant change. British Association of Otolaryngologists. more than 1–2 monthly) laser treatment. Squamous cell carcinoma and verrucous carcinoma are also more likely to occur in adults if the patient smokes. and to wait for resolution of the condition. 2000. 1991. Leuenthal BG. Wilson J (ed). Kashima HK. This increases the remission rate to approximately 50% in patients below 16 years of age. arising from the free edge of a vocal cord. Isotretinoin therapy for recurrent respiratory papillomatosis. Remission can take place at any age and does not seem to be related to treatment. 325: 613–617.

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Related topics of interest Lasers in ENT, p. 147; Paediatric airway problems, p. 232; Paediatric endoscopy, p. 237; Stridor and stertor, p. 311.

PERILYMPH FISTULA

Definition A perilymph leak into the middle ear arising from a defect of the oval and/or round window. It should not be confused with labyrinthine fistula, which is a fistula in the cortical labyrinthine bone secondary to CSOM. It may or may not have eroded through the endosteum to cause a perilymph leak. Aetiology 1. Congenital middle and inner ear deformities, in particular Mondini’s dysplasia or when there is a malformed stapes superstructure. 2. Head injury. 3. Barotrauma. 4. Iatrogenic in particular following stapedectomy. Clinical features A congenital perilymph fistula (PLF) should be suspected in children with an unexplained fluctuating or progressive sensorineural hearing loss with or without vertiginous symptoms. An external ear deformity may occur with the middle and inner ear malformation. A similar history following a head injury, barotrauma or middle ear surgery should be regarded as secondary to a PLF until proven otherwise. Shea’s series of iatrogenic post-stapedectomy PLFs presented with a mild mixed hearing loss and occasional dizzy spells but in over 36000 otological operations he has not seen a spontaneous PLF. Schuknecht has never seen temporal bone evidence of a spontaneous PLF including the review of the temporal bones of patients reported by Kohut as having a PLF. The current consensus view now holds that a spontaneous PLF does not occur in an otherwise normal ear without the above risk factors. Investigations A high definition CT scan of the petrous temporal bone is mandatory in suspected congenital PLF. Many subjects demonstrate a minor or major aplasia (see congenital hearing disorders chapter), in particular an enlarged vestibular aquaduct or Mondini’s dysplasia. Eighty-five per cent of congenital PLFs will have anomalies of the stapes superstructure, incus, promontory or round window demonstrable on CT. It has recently been shown that 2 transferrin is found in all human CSF and perilymph but in the serum of only 1

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in a 100 subjects. In those where a PLF is suspected from the history but not confirmed by a tympanotomy, washings of the middle ear for 2 transferrin can be made. Difficulty arises in deciding whether CSF or perilymph is the responsible agent in head injury patients with a positive 2 transferrin test. Hazel has noted that positioning a patient with a suspected PLF with the affected ear uppermost often improves hearing thresholds presumably because little perilymph escapes due to gravity. Management The diagnosis of PLF can only be made at tympanotomy. Sixty per cent arise from the oval window, 20% from the round window, 20% both windows, and 20% are bilateral. The oval or round window should be plugged with a fat graft, temporalis fascia or a vein graft. This is held in position in oval window PLF with a stapes prosthesis provided the incus superstructure is not malformed. Fibrin glue and more recently the KTP laser have been suggested to properly anchor an oval or round window graft in position. Temporalis muscle may be used to splint a round window graft reinforced by fibrin glue. Follow-up and aftercare Bed rest in the sitting-up position for 2–6 weeks is recommended as is avoiding straining or flying for three months. Diving is contraindicated. The patient is advised to cough or sneeze with the mouth open to reduce the chance of air entering the Eustachian tube and displacing the graft. One week of antibiotic cover is recommended. Further reading
Shea JJ. The myth of spontaneous perilymph fistula (Editorial). Otolaryngology Head and Neck Surgery, 1992; 107: 613–616. Schuknecht HF. Myths in neurotology. American Journal of Otolaryngology, 1992; 13:124–126. Kohut RI, Hinojosa R, Ryu JH. Perilymphatic fistulae: a single-blind clinical histopathologic study. Advances in Otorhinolaryngology, 1988; 42:148–152. Bassiouny M, Hirsch BE, Kelly RH, et al. 2 transferrin application in otology. American Journal of Otolaryngology, 1992; 13:552–555.

Related topics of interest Labyrinthitis, p. 134; Chronic suppurative otitis media, p. 38; Cholesteatoma, p. 35; Osteosclerosis, p. 223.

PHARYNGEAL POUCH

Diverticula of the pharynx are uncommon. The term pharyngeal pouch refers to a posterior pharyngeal pulsion (Zenker’s) diverticulum, and this has an incidence of approximately 1 case per 200 000 population per year. Other diverticula are very rare but include congenital lateral diverticulae, pharyngoceles and posterolateral pharyngeal diverticula. Aetiology and pathogenesis The cause of pulsion diverticulae is unknown. They arise posteriorly by herniation of the pharyngeal mucosa through a relatively unsupported part of the posterior pharyngeal wall known as Killian’s dehiscence. This weak area is at the lower part of the inferior constrictor muscle and is bound superiorly by the thyropharyngeal fibres and inferiorly by the cricopharyngeal fibres of this muscle. The pathogenesis is probably multifactorial, in part the result of a weakness at Killian’s dehiscence, incoordination of the pharyngeal phase of swallowing and cricopharyngeal spasm causing high intrapharyngeal pressure. A hiatus hernia and gastro-oesophageal reflux are sometimes present. Once a pouch is formed, food enters it and stretches it even more so that it enlarges. It may remain static for many years or slowly increase in size until it eventually passes into the posterior mediastinum. When the pouch reaches a moderate size it lies in line with the oesophagus and food may enter it preferentially. Pressure from the pouch may then be exerted on the oesophagus from behind to cause dysphagia. Clinical features Pharyngeal pouches are most frequently seen in the elderly. They cause a sensation of a lump in the throat, long-standing dysphagia, regurgitation of undigested food, halitosis, weight loss and recurrent chest infections due to aspiration. Hoarseness is unusual, but may occur as a result of irritation of the vocal cords from repeated aspiration or more rarely as a result of involvement of the recurrent laryngeal nerve by a carcinoma arising in the pouch. Rarely, a pouche may have an invasive squamous cell carcinoma in its wall. Swelling in the neck may be present and is nearly always on the left side. It may gurgle on palpation (Boyce’s sign) and empty on external pressure. 1. Radiology. A lateral plain film of the neck may reveal an air bubble in the pouch, but the definitive investigation is a barium swallow, which demonstrates the pouch. 2. Endoscopy. Oesophagoscopy should be carried out to exclude the presence of carcinoma. The instrument usually enters the pouch and an anterior bar may be seen separating it from the oesophagus. This investigation is often performed immediately prior to surgical excision of the pouch. In such instances a

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nasogastric tube is passed and the pouch is packed with proflavine gauze after any debris has been sucked clear. This will aid identification of the pouch during surgery. Management 1. No treatment Each case must be judged on its individual merits, with the patient being fully aware of the possible complications and potential benefits of operation. No treatment is indicated for a diverticulum which is causing few symptoms or in patients who are old, infirm and in poor general condition. 2. Endoscopic dilatation of the cricopharyngeal sphincter with bougies is only temporarily effective in relieving symptoms. It does not remove the diverticulum, which results in an eventual recurrence, and there is a risk of perforating the sac. 3. Endoscopic division of the bar between the pouch and the oesophagus. This can be performed with scissors or diathermy (Dohlman’s procedure). It is a quick procedure and a reasonable treatment for the frail and the elderly. The procedure does not remove the pouch, but it relieves the symptoms and restores swallowing by dividing the cricopharyngeus and widening the mouth of the diverticulum. The major risks are haemorrhage, mediastinitis, surgical emphysema and later stenosis. Amendments to the approach include the introduction of a specialized endoscope with a split beak. Endoscopic staple guns (which divide the wall and staple it synchronously) are now commonly used. This is the treatment of choice in nearly all pouches as results are good, morbidity low, and hospital stay short. 4. Pouch inversion. In this procedure a cricopharyngeal myotomy is performed and the pouch is mobilized, and then invaginated into the oesophagus and its neck oversewn with vicryl sutures. This operation avoids the risks of opening the sac, has a low complication rate and requires only a short hospital stay. This is the preferred treatment for small pouches. 5. Diverticulectomy. Excision of the diverticulum combined with a cricopharyngeal myotomy has remained a treatment of choice for many years. It now tends to be used for the very large pouches or when one of the other approaches has failed. The operation is performed in two stages, the first of which is the oesophagoscopy and the second the external approach to excise the pouch. Nasogastric feeding is continued for 5–7 days postoperatively, after which fluids are given. If there are no problems the tube is removed and a soft diet can be commenced the next day. Complications 1. Immediate. • Primary haemorrhage. • Surgical emphysema (mucosal tear or incomplete suture line). • Pneumothorax. 2. Intermediate. • • • • • Secondary haemorrhage (infection). Hoarseness (recurrent laryngeal nerve damage). Wound infection. Fistula (usually the result of infection). Mediastinitis (leak tracking downwards).

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3. Late. • Persistent hoarseness (recurrent laryngeal nerve divided). • Stricture (too much mucosa excised when dividing the neck of the sac). • Recurrence (endoscopic diathermy 7%, diverticulectomy 2–3%). Further reading
Bowdler DA. Pharyngeal pouches. In: Scott-Brown’s Otolaryngology, vol. 5, 6th edn. Hibbert (ed.) London: Butterworths, 1997: Chapter 10. Parker AJ, Hawthorne MR. Endoscopic diverticulotomy versus external diverticulotomy in the treatment of pharyngeal pouch. Journal of the Royal College of Surgeons of Edinburgh, 1988; 33:62–64.

Related topics of interest Globus pharyngeus, p. 113; Hypopharyngeal carcinoma, p. 124.

PHARYNGOCUTANEOUS FISTULA

Definition A fistula is an abnormal communication between two epithelial-lined surfaces. A pharyngocutaneous fistula is an abnormal tract joining the pharynx to the skin of the neck. Pathology Fistulae are unlikely after closed pharyngeal surgery but may occur following open surgery to the head and neck in which the pharyngeal mucosa has also been damaged. Consequently, laryngectomy is the most commonly associated procedure, but it may occur after pharyngeal pouch surgery, partial pharyngectomy or major oropharyngeal procedures (e.g. commando operation). Risk factors are: • Previous radiotherapy. • Infection (a persistent cough from a chest infection will put strain on the repair, and infection of the operated site will cause necrosis of the affected tissue with a leak through this defect). • Postoperative haematoma/chylous fistula/seroma. • Residual disease. • Poor nutritional status. • Poor surgical technique. Clinical features The patient most commonly develops a pyrexia 3 or 4 days postoperatively, associated with cellulitis of the neck wound. A swinging pyrexia and abscess formation may ensue. Typically on the seventh day the collection will rupture and a fistula will form. At this stage there will be a discharge of mucopus and the patient’s general condition will improve. In time, the discharge will become more mucoid than purulent and ultimately saliva alone is discharged. In many cases spontaneous resolution will occur, usually within 6 weeks. In persistent cases, especially in those having residual tumour or previous radiotherapy, there is the uncommon but ever present spectre of a carotid blow-out.

After rupture. this initial stage taking 2 or 3 weeks. depending on the surgeon’s experience and microvascular training. Provided that the fistula continues to reduce in size. It is suggested that nasogastric feeding be continued in this group for a further week and the gastrograffin swallow thereafter repeated. however. the diagnosis may be confirmed by a gastrograffin swallow. If a local flap fails or the defect is too large to consider this. If the size does not reduce over any 2week period after the initial separation stage. especially from a red fluctuant swelling in the neck. although they are at a higher risk of developing a stenosis at the level of the fistula. because local tissue is relatively ischaemic either as a result of previous radiotherapy or because of scar tissue formation during healing. These often fail. electrolytes and serum proteins should be checked regularly and the haemoglobin kept above 10 g/dl. Two flaps are often needed because it is important to line the mucosal and cutaneous surfaces with skin. a deltopectoral flap or a radial forearm fasciocutaneous microvascular flap. and if personal and home circumstances are suitable the patient can be allowed home and reviewed regularly in outpatients. a prudent plan would be to endoscope the patient under a general anaesthetic to exclude recurrent disease then to proceed with a repair. no surgical intervention is necessary. The wound should be cleaned regularly and absorbent dressings used to avoid maceration of the surrounding skin until all necrotic tissue has separated and healing has started. . the repair method of choice is. if the tract is small. A gastrograffin swallow performed on the 10th to 12th postoperative day will show an anterior sinus in about 15% of patients. Occasionally a fistula occurs several days after commencing oral feeding in patients who have had an apparently uncomplicated postoperative course. although granulation tissue should be biopsied to exclude recurrent disease in cancer patients. In most cases the sinus will have resolved. If the fistula opening is less than 1 cm diameter. Management A pharyngocutaneous fistula is initially managed conservatively. Follow-up and aftercare Patients who have had surgery for a fistula are followed up at the same interval as those who did not develop a fistula. Nasogastric or gastrostomy feeding continues until the fistula has healed. a local rotation skin flap should be considered in the first instance. but occasionally the stenosis recurs persistently and frequently so that excision of the affected segment with reconstruction is indicated. With persistent and profuse discharge from a fistula.PHARYNGOCUTANEOUS FISTULA 251 Investigation The diagnosis will be strongly suspected from the clinical features. Those who have had surgery for benign disease are unlikely to develop a stenosis. and it is this group who are at a significantly higher risk of developing such a fistula. This may settle after several dilations. a choice of: a pectoralis major myocutaneous flap. but followup for a year to exclude a late onset would seem sensible. The repair method of choice is a microvascular jejunal loop because of its low morbidity and mortality compared with a gastric transposition. but if not the process is repeated until healing is complete. The size of the external opening of the fistula should thereafter be measured weekly. The fistula may take many weeks to close spontaneously. the urea.

p. In: Million RR. Reconstructive surgery. Flaps and grafts for reconstruction. Cassisi NJ (eds). 143. p. Radiotherapy. p. Philadelphia: J. . 2nd edn. 267. Management of Head and Neck Cancer.252 OTOLARYNGOLOGY Further reading Stringer. 1994:157–169. McCombe AW. 124. Radiotherapy and complications of laryngectomy. Laryngectomy. Oropharyngeal carcinoma.B. 1993. p. Journal of Laryngology and Otology. 203. p. 264. Jones AS. 107:130–132. Related topics of interest Hypopharyngeal carcinoma. SP. Lippincott.

Hearing loss in a young patient. This can lead to secondary neural degeneration in the spiral ganglion. although men tend to have a slightly worse loss for the same age group. Circulatory changes such as arteriosclerosis. impairment. Men and women are both affected. The end result in most instances will be a combined sensorineural. 1. particularly at the basal end of the cochlea. In the absence of any other otological pathology the clinical examination is normal bar the hearing loss. Cellular degeneration gives rise to a reduction in the numbers of inner and outer hair cells. Peripheral degeneration is reported to be responsible for at least two-thirds of the clinical features of presbyacusis. Degeneration in the central pathways leads to a reduction in performance in terms of signal processing. Clinical features Moderate hearing impairment (45 dB hearing level averaged over 0. there is a progressive degeneration in the auditory system with ageing. Recruitment is a frequent problem and adds to the distortion. A variety of possible mechanisms exist. Investigations In the presence of an appropriate history and a symmetrical sensorineural hearing loss on pure tone audiometry. little further investigation is required. MRI scanning may be necessary to exclude an acoustic neuroma in any patient thought to be at risk. depending on . asymmetry on a pure tone audiogram. Many patients eventually become socially isolated and even depressed. which leads to hearing impairment in the affected individual. 2 and 4 kHz) occurs in 4% of the age group 51–60 but in 18% of those aged 71–80. so that they find conversations difficult to follow. atrophy of the stria vascularis and microangiopathy can lead to metabolic upset and further cell death. unilateral tinnitus or a conductive component to the audiogram will require investigation in its own right. rather than a sensory or neural. This leads to an elevation of hearing thresholds and a loss of frequency selectivity. Patients typically complain of difficulty in hearing which is worse in the presence of background noise. Although several different audiological patterns of hearing loss have been described. Presbyacusis is defined as the lessening of the acuteness of hearing that characterizes old age.5.PRESBYACUSIS As with all sensory systems in the human body. Pathophysiology Both the sensory peripheral (cochlea) and central (neural) components of the auditory system are affected and the deterioration appears to become more rapid with increasing age.

Rehabilitation. Clinical characterisation of the hearing of the adult British population. 1999. This system is now available in many public places such as churches. only 18% of the elderly with hearing loss have and use hearing aids. acoustic feedback and difficulty with manipulating the aid. Follow-up and appropriate support for all patients issued with a hearing aid should be mandatory. Further reading Browning GG. concert halls and lecture theatres. Hearing in the aged. Accessory aids. Simon HJ. It is likely that this aspect is the most important in hearing aid provision. 1991. Hearing aid uptake may be improved by the proposed introduction to the NHS and improved performance of digital hearing aids.254 OTOLARYNGOLOGY the predominant histological changes. Acta Otolaryngologica. 31:217–223. 3. The ENT surgeon or audiologist therefore has no idea if the patient has benefited from the treatment. There are several reasons for this. Obtaining a hearing aid has become less of a problem for many patients since the introduction of direct referral schemes from general practice. perhaps because the patient experiences some of the difficulties outlined above. which may be dictated by further hearing deterioration with the passage of time. Management As there is no curative treatment for deafness associated with ageing. An induction coil fitted to the telephone or television may help some patients. Hearing aids. Some patients may be helped by rehabilitation in the form of speech reading or auditory training. Suppl. G. Follow-up and aftercare Audiological support is initially required to familiarize and rehabilitate the user with the aid. The role of rehabilitation and its benefits for the average hearing-impaired individual are not proven. Current Opinion in Otolaryngology Head and Neck Surgery. The European Concerted Action Project. in general a sloping high-frequency loss is the commonest pattern found. In the longer term. Although about 75% of hearing aid users are over the age of 60. to provide a hearing aid and rehabilitate the patient. The sound is transmitted by induction from a special attachment and is picked up by the patient’s aid when it is switched to the T position. Any difficulties the patient might have can then be identified and dealt with. 476. 1. Salomon. vanity. 7:282–289. Many hearing aids dispensed are not used. access is required for repairs and replacements. 1983. Divenyi PL. Some patients have minimal handicap from their hearing difficulty despite a significant loss and therefore do not present themselves to medical services. . the main aims in management are to assess the degree of disability. Advances in Otorhinolaryngology. including denial of hearing impairment. Davis A. In some centres patients provided with a hearing aid are not seen again. In those with neural presbyacusis poor speech discrimination may limit the benefit of amplification as may the performance of the aid itself. Hearing in ageing: issues old and young. 2.

254. p. Pure tone audiogram.PRESBYACUSIS 255 Related topics of interest Evoked response audiometry. Noise-induced hearing loss. 78. p. p. . Hearing aids. p. 117. 192.

2. the mean level being 0 dB HL. This standard represents the thresholds at each test frequency for a group of presumed otologically normal young adults. so doubling sound intensity corresponds to a 3 dB increase. . The amount of energy at 0 dB HL at each frequency is not the same. Therefore: Sound intensity (Ix) in dB=10 log10 Ix/Io where Io=10–12w/m2 Since sound intensity is proportional to the square of the sound pressure then: Sound intensity in dB=10 log10 sound pressure2 or = 20 log10 sound pressure level Log10 2 is about 0. Hearing level scale (dB HL or dB ISO). but the perception of only doubling the loudness. The clinical audiogram therefore gives an estimate of the subject’s hearing relative to normal. Introduction The ear responds equally. where the reference zero is an internationally agreed standard. The bel is the log to the base 10 of the ratio of the sound intensity being measured to a reference intensity which is constant.PURE TONE AUDIOGRAM The pure tone audiogram is probably the cornerstone of clinical auditory assessment. In other words. A decibel scale of human hearing was designed so that 0 dB hearing level (HL) would be the expected threshold of detection of a pure tone irrespective of its frequency. not to equal increments. and is measured in W/m2. The decibel is 10 times this ratio.3. The detection of sounds in decibels of sound pressure level (dB SPL) produces a pure tone audiogram which in normal circumstances would not be flat. but to equal multiples of sound intensity. In terms of pressure. Sound pressure level scale (dB SPL). The auditory system is less efficient at detecting sounds at the upper and lower ends of the frequency spectrum than in the middle regions. It was considered that the use of a dB SPL scale in pure tone audiometry would make abnormalities difficult to identify. Each 10 dB increase represents a 10-fold increase in the intensity of sound (log1010=1). that is the minimum sound level at which a specific response can be obtained. the threshold of hearing corresponds to a sound pressure level (dB SPL) of approximately 20 x 10–6 pascals and the threshold of pain to a level of 200 pascals. Decibel scales 1. a 3. It is measured in relative terms (dB ISO). In the dB HL scale normal hearing individuals would be expected to have a flat audiogram. intensity is exponentially related to loudness perception and therefore a logarithmic scale to measure loudness is necessary. It is a psychoacoustical test which aims to establish the subject’s pure tone hearing threshold.3-fold increase in sound pressure.

1000. Earphones are used for air conduction and the subject is asked to signal by pressing a small hand-held button as soon as the tone is heard. For this reason 5 dB steps are used for clinical audiometry. masking is used to raise the threshold in the non-test ear using air-conducted sound. Thresholds are ascertained using a psychophysical method of limits. Background Pure tones of several frequencies are tested. The ear is not equally sensitive to sounds of different frequencies. When the skull is set in vibration by a bone conduction vibrator. 2000. with a standard error of 3–5 dB. then the bone conduction thresholds will appear to improve because of the addition of the middleear component. It is particularly sensitive to sounds in the ‘speech frequencies’ (500–4000 Hertz) and progressively less so to sounds of lower and higher frequencies. Bone conduction is taken to give an indication of cochlea function. which reduces the contribution of very low and very high frequencies to the overall noise level measurement. In addition it appears that the ear is less easily damaged by the sound frequencies to which it is less sensitive. 1000. but because a variety of routes for the transmission of sound to the cochlea exist for bone conduction. This continues in the following order: 1000. 2000. This overcomes any cross-hearing (the interaural attenuation for air conduction is of the order of 40–60 dB when wearing headphones) and allows an accurate assessment of the true threshold of the test ear for either air or bone conduction. it is not an absolute representation of inner ear threshold. Smaller steps could be used (e. 8000. To take account of this an’ A. the sounds reach the inner ear by the direct osseous route or via transmission across the middle ear. 4000 and 8000 Hz for air conduction (although 3000 and 6000 Hz will be required for noise-induced hearing loss claims) and 500. The A-weighted scale (dB A). The intensity is reduced in 10 dB steps until no sound is heard. . In the context of pure tone audiometry.PURE TONE AUDIOGRAM 257 3. Tones are first presented at an intensity above the patient’s suspected threshold. Method The subject is seated in a soundproof room and the procedure is explained by the examiner. 4000. 2000 and sometimes 4000 Hz for bone conduction. With any psychoacoustic test there is a variation in the results obtained in any test-retest situation. The signal is then increased in 5 dB steps until half of the tone pips are consistently heard. 500. If the middle-ear defect is corrected. Finally 1000 Hz is tested again to check on subject accuracy and should be within 10 dB of the first result. Pure tones are produced by a calibrated audiometer and are first presented to the subject’s better ear. The timing and duration of signal presentation should be varied and no visual clues should be offered. usually 250. 2 dB) but the procedure would be markedly prolonged without significantly improving accuracy. The second ear is then tested in identical fashion.g. This causes an artificial depression of the bone conduction thresholds whenever a conductive defect is present. and at 250 Hz are often not representative as they may be felt rather than heard.weighting’ is used. This dB A scale is used in industrial and other noise exposure settings. Masking Masking is the phenomenon by which one sound impairs the perception of another. 500 and 250 Hz. The results of bone conduction become less reliable at and above 4000 Hz. This has become known as the ‘Carhart effect’ after he described it in patients who had successful fenestration surgery for otosclerosis.

but if the result is unusual it will require manual confirmation. narrow band noise with a central frequency identical to the test tone is used. 194. Leijon A. Quantization error in clinical pure-tone audiometry. 2. p. 192. Scandinavian Audiology. Variations 1. London: Butterworths. Bekesy audiometry. (c) Bone conduction testing whenever the unmasked bone conduction is 10 dB or more better than the worse air conduction. Recommended procedures for puretone audiometry using a manually operated instrument. Related topics of interest Noise-induced hearing loss. There are three scenarios when masking is essential: (a) Masking must be applied to the better ear when testing air conduction in the deafer ear if the difference in unmasked thresholds is found to be 40 dB or more (to prevent interaural attenuation).g. British Journal of Audiology. Although still used for screening industrial hearing loss. Thus a zig-zag printout is obtained from which thresholds at each frequency can be estimated. recruitment and nonorganic hearing loss can be provided. Computerized pure tone audiometry. continuous/pulsed tones) additional diagnostic information about adaptation. The masking noise is delivered by an ear insert for bone conduction and headphones for air conduction. 1981. p. (b) Air conduction studies whenever the unmasked bone conduction is 40 dB or more better than the worse air conduction. forward/backward sweeps. 1986:38–47. When the signal cannot be perceived the button is released which increases the intensity again. the method has fallen into disuse for most other problems because it is too unreliable. 21:103–108. The subject alters the intensity of the tone by pressing a button if the tone is heard which lowers the intensity of the signal. The masking level in the non-test ear is determined by shadow masking and recording the thresholds on a masking chart. Non-organic hearing loss. Further reading British Society of Audiology/British Association of Otolaryngologists. 15:213–216. In: Clinical Otology and Audiology. As the test can be self-administered and provides an automatic printout.258 OTOLARYNGOLOGY As masking is most effective when the frequency of the masking noise overlaps the test tone. . Browning GG. 1992. Audiometric tests. By varying the test technique (e. In essence this is identical to the above but a microprocessor presents the tones and analyses the responses against predetermined values. it is ideal for workforce screening. This variant uses a special audiometer which automatically sweeps from low to high frequencies while presenting continuous or pulsed tones. It is useful as a screening test and in very busy clinics.

Image acquisition is preferably at the rate of 2 frames per second during a bolus swallow. The radiation dose of a 4 projection sinus series is equivalent to 25 chest X-ray doses or 10 weeks of background radiation. obscuring the area for further follow up studies and being a viscous thick suspension it is less likely to demonstrate small oesophageal leaks than water soluble contrast). pharyngeal webs (the web is a line indenting the anterior aspect of the barium column at the level of C5/6) and cricopharyngeus hypertrophy (indents the posterior column of barium at the C6/7 level). Barium swallows are of superior sensitivity in demonstrating pharyngeal pouches. Unenhanced CT scans are usually performed for the assessment of benign sinus disease prior to functional endoscopic sinus surgery. Lateral soft tissue views of the neck are of limited value in isolation.RADIOLOGY IN ENT H. Motility disorders are best assessed using dynamic video swallow fluoroscopy. Computerized tomography CT provides vastly improved delineation of bony structures and of soft tissue structures of the head and neck compared with plain films. and of the temporal bone for assessment of bony . but many foreign bodies are likely to be non opaque. They may demonstrate opaque foreign bodies. when perforation of the oesophagus is suspected or a surgical anastamosis is being evaluated (barium used in these circumstances will remain in the soft tissues if a leak is present. The Royal College of Radiologists’ guidelines recommend that ‘plain films of the sinuses are not routinely indicated’.Lewis-Jones Diagnostic imaging techniques Plain films Following the increased use of complex diagnostic techniques such as CT and MR. plain films are rarely used for diagnostic purposes in ENT. Water soluble contrast swallows (using non ionic relatively inert contrast media) are indicated when the history suggests that aspiration into the lungs is a real risk (if barium is used in these circumstances it may lead to resistant chest infection or permanent lung damage). Contrast swallows are more accurate in this situation. Digital screening is preferred to reduce radiation dose. Contrast swallow A contrast swallow is indicated in the investigation of dysphagia or symptoms suggestive of motility disorders.

therefore. but important. This is particularly useful in oncology and in complex anatomical evaluation of the temporal bone. These characteristics are represented in T1 or T2 weighted imaging sequences. The T2 weighted images tend to provide lower resolution images in terms of anatomy. but with fat signal suppression. Energy in the form of a radio wave is transmitted into the body at a precise frequency causing the protons to resonate. is related to the time taken for excited spinning protons to return to their normal position in the magnetic field. Modern multi-slice CT scanners can now acquire data volumetrically allowing multi-planer recontruction of CT images. T1 weighted images provide high resolution of anatomy and excellent soft tissue detail. therefore. which has the benefit of opacifying blood vessels making lymph node enlargement easier to detect. CT is disadvantaged in the densest part of the skull base where artefacts are commonly caused in the adjacent soft tissue due to X-ray absorption in dense bone. in abundance in the body. the T1 spin lattice or longitudinal relaxation time. the T2 spin spin or transverse relaxation time. The images generated. Table 1 below shows patterns of tissue characterization. The resonant radiowave is then turned off and protons gradually relax back into the direction of the magnetic field giving off a radiowave which is detected as the MR signal. The second. and it also relates the MR characterization to CT appearance. Gadolinium is a paramagnetic contrast agent used in MRI It behaves in exactly the same way as iodine based contrast media described in the CT section. This leaves pathology and fluid including oedema as white in the image and more conspicuous than in ordinary T2 weighted images where high signal fat may well obscure the boundaries of a tumour. set of MR images is worthy of mention. but provide better contrast for the detection of abnormal tissues such as tumour or inflamed tissue. A final. the STIR sequence. Magnetic resonance imaging MRI provides markedly superior delineation of soft tissues in any imaging plane. Pathological enhancement in the brain is. and also of demonstrating abnormal areas of enhancement. . T1 weighted images are used to demonstrate enhancement (an increase in signal) with gadolinium. which when placed in a strong magnetic field act like small metallic dipoles and align predominantly in the direction of the magnetic field. but not into cells. whereupon they realign in a direction against the magnetic field. depends on excited spinning protons moving out of phase with each other as they relax. This creates images with a T2 weighting. The T2 weighted images are good at detecting abnormal biochemistry related to abnormal tissues. In tumour work it is routine to administer iodine based intravenous contrast. Enhancement of an area directly indicates its vascularity and the degree of enhancement shown in MRI is in the range of 50–100 times greater than that shown in CT. and this causes abnormal tissues to enhance (appear white). more conspicuous. where observation of signal on T1 and T2 weighted images allows identification of tissue type. Intravenous contrast usually flows from the vascular compartment into the extra cellular compartment.260 OTOLARYNGOLOGY anatomy. In abnormal tissues it leaks into the intra cellular compartment. This sequence is of great value in the delineation of head and neck cancers. The only exception to this rule is in the brain where the blood-brain barrier prevents contrast flowing into the extra-cellular compartment also. One of these components. The fundamental imaging unit in MR is the proton or hydrogen nucleus. represent the biochemical composition of tissues in the body and it is this concept of tissue characterization through MRI that makes soft tissue delineation so superior. The MR signal given off by protons can be detected and resolved into two different components.

it is very operator dependent requiring an ultrasonologist with specific technical skills who performs head and neck ultrasound regularly. It is indicated as the first line choice of radiological investigation when chronic middle-ear disease is being investigated. High resolution CT (1 mm slices). 2. bone algorithm. iron containing brain clips. in the first trimester of pregnancy. however. Ultrasound Ultrasound is a very useful technique for the assessment of masses in the neck. A high frequency (7. performed as an outpatient procedure at the time of diagnostic scanning. ENT pathology Temporal bone disease The choice of investigation rests between CT and MRI. Correlation of MR and CT appearances of tissues MR cannot be used in patients with cardiac pacemakers. however. MRI. Developmental anomalies including vestibular aqueduct dilatation can usually be identified on a high resolution T2 weighted MRI. As a technique. The high resolution T2 weighted technique must identify the normal facial and acoustic nerves separately within the internal acoustic meatus to successfully exclude small intracanalicular neuromas.RADIOLOGY IN ENT 261 Table 1. 1. It does not involve any radiation exposure and can be linked with ultrasound guided fine needle aspiration. when the diagnosis of cholesteatoma is suspected. for trauma induced deafness and suspected otosclerosis. This will provide evidence of abnormal appearance at this . It does. It is also used for specific cases following MRI (see below). involve a high radiation dose (100 chest X-ray-equivalents or 1 year background radiation). High resolution T2 weighted MRI of the temporal bone is now the accepted screening tool for patients with suspected acoustic neuromas although gadolinium enhanced MRI remains the gold standard for detection of small acoustic neuromas. certain cardiac prosthetic valves. thyroid goitres and for suspected salivary gland pathology.5–10 mHz) hand held probe is placed directly on the neck and the fine needle can be visualized directly entering individual lesions as small as 1 cm in diameter. or in patients with cochlear implants. This provides superb bony detail of both the inner and middle ear structures. in particular.

but a tumour should be excluded. Sinus disease CT is indicated following failure of medical treatment and on consideration of functional endoscopic sinus surgery. Differentiating oedema from tumour can be difficult. low lying or asymmetrical cribriform plate. High resolution T2 weighted MRI is also a useful screening test for evaluating congenital deafness. a contrast enhanced spiral CT or contrast enhanced MRI is indicated. 3. This technique is also of value in diagnosing cavernous or lateral sinus thrombosis. whether the cause is related to the osteo-meatal complex and its nature (inflammatory sinus disease associated with parallel walled mucosal thickening. Gadolinium enhanced MRI provides the superior soft tissue delineation required for defining the extent and spread of these tumours. Head and neck cancer 1. Oral cavity and oropharyngeal tumours. High radiation doses is a particular problem with CT of the sinuses and for this reason a low dose protocol is recommended. allergic sinus disease associated with nodular and irregular mucosal thickening+or—polyposis). This is often clinically occult disease. Spiral CT is regarded as superior. predominantly as it minimizes movement/swallowing/breathing artefact. Moving blood can be specifically identified in an ultra fine slice and placed in a 3D matrix representing the vascular tree. Destructive lesions of the temporal bone apex or elsewhere at the skull base should be imaged in all three planes. In equivocal cases MR angiography or venography is indicated. This involves: • Coronal images 2 mm cuts every 8 mm from anterior frontal sinus to posterior border of sphenoid sinus. If a tumour is suspected.262 OTOLARYNGOLOGY site. CT also appears superior to MRI in the detection of early thyroid cartilage invasion (this is seen initially as some . particularly those which place vital structures under increased risk of damage during endoscopy. Bone destruction of the mandible is best evaluated using a combination of isotope bone scan with plain film. one through the frontal sinus to show the posterior sinus wall and the second through the apex of the orbital foramen to show the relationship of sinuses to the optic nerve. MRI is accurate at showing vascular occlusion or encasement by tumour. onodi cells next to the optic nerve. Absence of caries associated with increased activity indicates bone invasion. secondary to orbital or mastoid infection. Hypopharynx and larynx. The scans would identify the pattern of sinus disease. Bone destruction can be seen with polyposis and fungal disease. and supplemented by high resolution CT of the affected area if surgical treatment is contemplated. This does not require arterial or venous catheterization or even intravenous contrast. Skull base and nasopharynx. 2. CT and MRI are comparable at staging tumours at this site. All anatomical variants should be identified. • Two axial cuts are also performed. Multi-planar MRI with gadolinium enhancement is the first line investigation supplemented with high resolution CT if focal bone destruction is suspected. The plain film OPG allows accurate detection of dental caries which can cause increased activity on the isotope bone scan (and otherwise a false positive result). The radiation dose is equivalent to 80 chest X-rays or 10 months of background radiation. presenting with cranial nerve palsy or neuralgia.g. dehiscent roof of carotid canal in the sphenoid sinus. It may be necessary to recall the patient for images in the sagittal plane to allow accurate measurement of the vestibular aqueduct in equivocal cases. e.

It is suggested that CT scan of the thorax should be routinely performed in patients with head and neck cancer who have a normal chest X-ray. but enlarged. as well as direct spread of tumour. The incidence of occult disease has been reported as high as 15%. If complex reconstructive procedures have been performed and there is a high likelihood of recurrence (close margins. • Grouping of more than three lymph nodes of 5–8 mm in one lymph node level. and makes scan interpretation difficult. These criteria will provide approximately 60% sensitivity and 95% specificity for lymph node involvement by tumour. which by definition are at an early stage. Even so. MRI has proven superior in detection of recurrence. CT and MRI can demonstrate lymph nodes in the neck. This will provide information regarding gland function and obstruction. There is 100% specificity for tumour involvement by squamous cell carcinoma. not all involved lymph nodes in an NO neck will be detected and if neck dissection is routinely planned. 4. although no other specific information will be obtained. This is also the case in the post-operative larynx. Ultrasound guided fine needle aspiration is the most accurate method of a radiological assessment of the NO neck. 6. Cervical lymph node assessment. Distant metastases. • All other nodes minimum axial diameter greater than 10 mm. Salivary gland pathology Control films with contrast sialography is still indicated for intermittent swelling of the major salivary glands. retrolaryngeal lymph nodes. Recurrence may take the appearance of a focal occult mass lesion at the site of reconstruction or of clinically occult lymphadenopathy. either metastatic or a synchronous primary bronchial neoplasm. 5. Recent studies have shown a high incidence of disease in the thorax. 7.RADIOLOGY IN ENT 263 sclerotic change within the cartilage before lysis occurs). MRI is probably superior in this regard as it can reveal oedema in adjacent anatomy. and are biopsied using a fine needle. Failed procedures usually in the submandibular area can be referred for isotope sialography. • Extracapsular spread: This is shown by attachment or invasion of adjacent structures. The technique involves identification of the 3 largest lymph nodes in the ipsilateral neck. again masked by post surgical or post radiotherapy fibrosis. . The NO neck. Imaging has low specificity levels due to variable ossification of cartilage in normal life. more than one involved lymph node at pathology unfavourable histology). Radiotherapy creates a great deal of oedema which can last up to 12 months following treatment. which is not detected by a plain radiograph. a baseline post-operative scan at 6 to 8 weeks is helpful. This gives an 85% sensitivity and 100% specificity for detection of tumour. Postoperative assessment. Stones and strictures can be treated percutan-eously under imaging guidance using micro angioplasty ballons and micro cages mounted on guide wires. CT of the thorax is probably not indicated for T1 N0 tumours. It is superior in the demonstration of small. All three imaging modalities use essentially the same criteria for nodal involvement by tumour: • Jugulo-digastric node with minimum axial diameter greater than 15 mm. then imaging or FNA of the nodes is of little value. Ultrasound. • Central necrosis: This is visible as cystic change within the lymph node and can be seen on all three modalities.

Differential Diagnosis in Head and Neck Imaging. Mack M. . Second Consensus. 180. 1999. Imaging should always be combined with clinical assessment and fine needle aspiration of the mass. MR or ultrasound. p. p. 108. p. p. Effective Head and Neck Cancer Management. if necessary. If endoscopy and the chest radiograph fail to identify the cause of laryngeal nerve palsy. Oral cavity carcinoma.264 OTOLARYNGOLOGY Salivary gland masses can be assessed. Balzer J. New York: Theime Publishers. MR can provide superior information re: (a) Characterization of cysts or lipomas. The PA chest radiograph is the first investigation. British Association of Otolaryngologists. Imaging can usually successfully identify benign salivary gland lesions. Wilson J (ed). Nasopharyngeal carcinoma. Imaging of the Head and Neck. allowing prioritization for potentially malignant masses. Related topics of interest Acoustic neuroma. Laryngeal carcinoma. Hypopharyngeal carcinoma. Imaging of the Paranasal Sinuses and Oro-maxillo-facial Region. Vogl TL. (c) Extension of the mass into the deep lobe of the parotid gland. by CT. 203. (b) The pattern of homogenous enhancement or non-homogenous enhancement. a spiral CT from skull base to the lower border of the lung hila is required. Carter BL. p. Steger W. 1993. Head and Neck Surgeons. 124. Philadelphia: Saunders. New York: Theime Publishers. Further reading Valvassori GE. 138. 1. p. Laryngeal nerve palsy Urgent endoscopy should be co-ordinated with radiological assessment. Radiological Clinics of North America. 1995. FESS. Matee BL. 2000. 197. p. Oropharyngeal carcinoma.

4. releasing energy. They are produced when high-speed electrons expelled by thermionic emission from an electrically heated tungsten filament are arrested by a target anode of high atomic number. Neutrons These are produced by bombarding stable nuclei with electrons in a cyclotron. Biologic principles Factors that affect the response of cells to a given dose of radiation include: • Radiosensitivity is an inherent characteristic of the cell (e. Gamma rays Radioactive atoms disintegrate to form a more stable atom. X-rays X-rays have a smaller wavelength than UV light and have high energy: kilovolts (kV) to megavolts (MeV). Megavoltage linear acceleration of the electrons produces X-rays in the energy range of 4–20 MeV. This may consist of high-energy electro-magnetic radiation (X-rays and gamma rays) or particulate radiation (electrons (beta particles) or neutrons). usually tungsten. 5. converting their kinetic energy into heat and photons. with a rapid fall-off in dose beyond this. which may be particulate (usually electrons) or uncharged electromagnetic radiation called gamma rays. They are used to boost the dose to a neck lump lying in close approximation to the spinal cord. Its role in head and neck cancer has yet to be defined but some authorities find it useful in the treatment of sinonasal and advanced salivary tumours. energy of 4–6 MeV is used. This is to a certain extent dependent upon cellular repair mechanisms. the maximum dose delivered is to the skin. Energy The amount of energy of a photon beam is described by the roentgen (R). However. OER for low . • Oxygen is a potent sensitizer. A photon is a quantum or bundle of electro-magnetic radiation. having the same wavelength and energy as X-rays. Electrons High-speed electrons can be used as an alternative to electromagnetic radiation.g. 2. Orthovoltage machines produce X-rays of about 300 kV. due to its ability to form free radicals. 3. while the gray (Gy) is the unit of absorbed dose by the tissues. The technique is more skin sparing than orthovoltage radiotherapy and is the treatment of choice for irradiating the nose and pinna.RADIOTHERAPY A. there is a relatively slow fall-off in dose with depth. For treatment of head and neck cancer. seminoma and leukaemia cells are exquisitely sensitive to radiation whereas glioma and melanoma cells are relatively radio-resistant). Oxygen enhancement ratio (OER) is the ratio between doses in hypoxic and euoxic cells to produce the same biologic effect. 1.. there is significant scatter and the dose is more difficult to map precisely.Shenoy Radiotherapy is treatment with ionizing radiation. They give a uniform dose up to a certain depth which varies depending on the energy of the beam. which are enhanced in melanoma cells.

Many tumours are thought to have hypoxic cores leading to radio-resistance. and systemic radioactive isotopes (i. use of lead alloy blocks (to reduce normal tissue included within the radiation fields) and use of wedges to alter the dose distribution. fraction size. so that a small increase in dose may greatly increase tissue injury. meaning the dose to hypoxic cells is three times greater than in oxygenated cells. S phase cells are relatively more resistant than M phase cells. Acceleration uses the same or slightly lower dose than conventional therapy with the same number of fractions delivered in a markedly reduced overall time. Normal cells are able to synthesize factors such as p53 protein. The intent is to reduce repopulation in tumours. The adoption of fractionation into radiation has led to the concept of four ‘Rs’ of radiobiology. Each tissue has its own tolerance level beyond which radiation toxicity will occur. High LET radiation (neutrons) have a more biologic effect than low LET radiation (X-rays). Resting cells may also sustain DNA damage. the total dose delivered is about 10 to 15% higher than conventional . Repopulation. as the fraction size is similar to conventional treatment. Clinical principles Radiotherapy should be defined in terms of type. multiple fields. • The position a cell occupies in the cell cycle determines sensitivity to radiation. Many manoeuvres are utilized to maximize the ratio including fractionation of dose. number of fractions. interval between fractions and volume treated. There are however more complex differences between various normal tissues and it is important to realise that prolonging treatment time has little effect on late effects. but because multiple fractions are used. are less likely to repair damaged DNA and more likely to undergo apoptosis before entering mitosis. prolonging the S-phase (synthesis of DNA). As a result. method of application. Omission of one or two fractions of radiotherapy. Maximizing the therapeutic ratio is the overriding principle of radiation therapy. The late effects are not reduced. allowing repair of damaged DNA before the next cell division. A higher proportion of malignant cells will therefore die from radiotherapy. DNA is most susceptible to lethal injury when the cell is dividing and is not able to repair DNA damage. Altered fractionations use more than one fraction per day and are essentially divided into two schedules of accelerated fractionation and hyperfractionation. five fractions per week over 5 to 7 weeks. Resting malignant cells have much less capability to arrest in S-phase. have a shorter cell cycle. Repair. and is the ratio between normal tissue complication dose to the tumour control dose. iodine-131 for thyroid cancer). Hyperfractionation uses less than conventional dose fraction in the same overall time. both fraction size and treatment time determine response of acutely responding tissues. perhaps because of acute side-effects. Conventional fractionation is defined as treating once daily at a dose of 1.266 OTOLARYNGOLOGY energy X-rays is between 2. while overall treatment time has little effect. Dose fractionation spares normal tissues because of cellular repair in between fractions and due to repopulation if the treatment time is sufficiently long. can significantly reduce the chances of cure. • Linear energy transfer (LET) is the amount of energy deposited as the X-ray travels through matter.8–2 Gy per fraction. The principle is to provide a sufficient dose to the tumour to effect a cure or adequate palliation but provide a minimal dose to the surrounding normal tissue in order to minimize complications. Malignant cells have a greater proportion of actively dividing cells (a larger growth fraction) and so a greater percentage of cells will die. interstitial brachytherapy. fraction size is the dominant factor in determining late effects in normal tissue.e. Redistribution and Re-oxygenation. There are various methods of application in the head and neck including external beam therapy (teletherapy) using linear accelerators or cobalt isotope machines. but a large sparing on early effects. for example iridium wires placed in flexible plastic tubes.5 and 3. In contrast.

Further reading Fu KK. Related topics of interest Hypopharyngeal carcinoma. Biol Phys. Accurate targeting is essential due the close proximity of vital but radiation-sensitive structures (cervical spinal cord. mucous membranes (mucositis. Radiat. A Radiation Therapy Oncology Group(RTOG) phase III randomised study to compare hyperfractionation and two variants of accelerated fractionation to standard fractionation for head and neck squamous cell carcinomas: first report of RTOG 9003. volume treated. 124. brain and spinal cord (transverse myelitis. Nasopharyngeal tumours. desquamation. p. Nausea and vomiting are less common. radiotherapy can damage skin (erythema. 2000. A variable margin around the tumour is included to allow for microscopic involvement. Use of wedges that attenuate a beam’s dose differentially across its width helps this. blocks and compensators. Oncol. Sinonasal tumours. Pajak TF. 197. cartilage (perichondritis). A computer maps out a plan of the dose applied to the tumour and surrounding structures by calculating the summation of the contributions of the applied beams modified by wedges. Int. 280. p. 48:7–16. lassitude and anorexia. 180. Two or more beams from different angles may be needed to obtain an adequate radiation dose to the tumour volume while maintaining surrounding tissue tolerance. and atrophy of sweat glands and other skin appendages). localized cortical radionecrosis) and bone (osteoradionecrosis). p. the total dose. p. the number of fractions and the total treatment time. Various trials have been performed which have demonstrated the clinical effectiveness of the above strategies and radiotherapy treatments using multiple fractions are being increasingly used in clinical practice. Oral cavity carcinoma.RADIOTHERAPY 267 treatment. Laryngeal carcinoma.. Typically. Side effects General side effects include tiredness. Local side effects depend on the type of radiotherapy. Trotti A et al. eye. . These blocks are marked on the shell. candidiasis and reduced saliva production due to minor salivary gland atrophy). 138. On a simulator (X-ray machine with image intensifier) the field is chosen and lead alloy blocks used to protect vulnerable structures. J. Treatment planning Examination and CT or MR scanning defines the treatment volume. The patient is immobilized in an individually made plastic head and neck shell. Verification radiographs are taken during the first fraction dose and compared with the simulation films to ensure that the field is correctly positioned. pharynx). p.

cosmesis. refined anaesthesia and microsurgery have allowed more major head and neck resection procedures to be developed. In addition some procedures took over a year to complete. We have classified reconstruction into four levels. In exposed wounds one needs to observe for a seroma. The depth of plane varies according to site.R. tumours or congenital deformity. Level 2 Skin grafts. The graft has no blood supply and so needs a vascular bed. It may be desirable to close small defects directly. They may be classified into split skin grafts (also called partial thickness skin grafts) or full thickness skin grafts (also called Wolfe grafts). The skin is able to be stretched but its tolerance varies according to site and age. It will not take on bone without periosteum. Level 1 Direct closure. while in 1936 Salmon confirmed the distribution of the perforating branches from marginal arteries.McRae Reconstructive surgery is the surgical technique to replace tissue loss caused by trauma. On the trunk and limbs it lies between the superficial and deep fascia. The advent of antibiotics. heavily irradiated tissue or on infected tissue. If a haematoma or seroma develops. Manchot in 1889 studied the blood supply of the skin and introduced the concept of vascular territories. haematoma or a collection of pus between the graft and recipient site. retention of function and quality of life were usually poor. Excision of a lesion should be planned so skin incisions are in the line of least tension as mapped out by Langer’s lines. for example over fat. cartilage without perichondrium or tendon without paratenon. Skin suturing should be without undue tension.RECONSTRUCTIVE SURGERY N. for example on the face the level of undermining is very superficial but on the scalp it is deep to the galeoaponeurotica.D. Although skin cover could be achieved by staged transposition of tubed pedicled fasciocutaneous flaps from distant sites. A skin graft is less likely to take at sites of poor vascularity. The contact between the graft and recipient site is maintained by a pressure dressing or by the exposed method. The development of one-stage pedicled myocutaneous flaps and microvascular free tissue transfer over the last 25 years has largely removed these criticisms with the consequential enormous improvement in the quality of life for head and neck cancer patients. it can be . undermining should be between tissue planes. A skin graft is a segment of epidermis and dermis that has been completely separated from the donor site and thus has no blood supply. The pressure dressing could a pressure bandage or a tie over dressing with foam or cotton wool. These lines are usually at right angles to the underlying muscle fibres.Niranjan and R. Following the excision.

it be placed keratin side down on tulle gras. The postauricular donor site is preferred because primary closure is easy and leaves an inconspicuous scar. advancement. Skin gets its blood supply either from direct cutaneous vessels which run superficial to the deep fascia or from indirect vessels which pass from feeding vessels through muscle or fascia to reach the skin. Split skin grafts. the use of relaxed skin tension lines should be used. They can be classified into random. These are fasciocutaneous flaps with a named blood supply running superficial to the deep fascia supplying the overlying skin. The inner aspect of the upper arm or thigh is therefore recommended. Indications (a) To cover donor sites. Random.5 mm is recommended for covering within the oral cavity.RECONSTRUCTIVE SURGERY 269 promptly dispersed by making a small nick in the graft and drawing out the collection using a sterile cotton bud. for example the inner layer of a maxillectomy cheek flap. for example radial forearm free flaps and deltopectoral flaps. which is rolled. Indications (a) Nasal tip and conchal bowl defects. to line the orbital cavity after exenteration or as a cover for a floor of mouth or tongue raw surface. Axial. The donor site should be hairless and inconspicuous. These are skin flaps that remain attached at their base to provide a blood supply and lymphatic drainage. When planning such a flap the length of the flap should not exceed the width of the base otherwise the distal portion of the flap may become ischaemic. Level 3 Pedicled skin flaps. (c) To line cavities. Examples of random skin flaps are Z-plasty. placed in a sterile pot and refrigerated at 4°C. after taking the graft at operation. which may still occasionally be used to replace lateral . Where possible. Full-thickness skin graft (Wolfe graft). (b) A full-thickness graft with all adipose tissue excised is ideal when performing a septodermaplasty.3– 0. This consists of the epidermis and the whole of the dermis. A thicker graft of 0. Although these flaps may be raised anywhere and run in any direction. rotation or transposition skin flaps. A random flap is one where there is an indirect or an unknown direct blood supply to the skin. It should be noted that the dermatome scale acts as a guide only: other factors such as angle of the dermatome to the skin and skin tension will alter the graft thickness. (b) To cover excised conchal bowl skin and cartilage defect after the excision of a basal cell carcinoma. careful planning is necessary to obtain optimal cosmesis. Examples include deltopectoral and nasolabial flaps. Split skin grafts consist of epidermis and a thin layer of dermis. The pectoralis major myocutaneous flap has replaced many of the indications for the deltopectoral flap. It is recommended that. Immediate grafting with quilt suturing and cross-hatching of the graft is recommended so that blood and serum can escape and do not lift the graft from its bed. Unroll the graft onto the donor site after 3–5 days when all bleeding and serous ooze from the raw bed has stopped and vascular granulated tissue has started to form. rhomboid. axial and myocutaneous. The length of the flap corresponds to the area supplied by these vessels.4 mm. but the troughs of the rete pegs and epithelium lining the hair follicles are left in situ to allow re-epithelialization of the donor site should be harvested using an electric dermatome set at 3 or 4 on the circular scale corresponding to a thickness of 0.

Two important points in technique in raising the flap are: (a) suture the muscle edge to the subcutaneous edge as the flap is raised to prevent shearing of the perforating vessels. Musculocutaneous. (b) after measuring the flap allow an extra 1–2 cm of pedicle length as the flap retracts on raising. Reconstruction of mandibulectomy greater than 8–10 cm. soft palate and the repair of a pharyngocutaneous fistula. the second to return the pedicle to its original site after the distal portion has gained an adequate blood supply at its new site. Between stages the patient must endure moist dressings to an unsightly granulating bed from which the flap has been lifted. Reconstruction of a neopharynx after pharyngolaryngectomy. Good results require sound microvascular training and meticulous attention to detail. Its advantages are that it is straightforward to raise. These flaps provide the gold standard in terms of cosmesis and preservation of function. Common free tissue transfer flaps in head and neck reconstruction with their main indications are: (a) Radial forearm fasciocutaneous free flap. Level 4 Free tissue transfer. A pectoralis major flap is an example. Its main disadvantage is that its bulk may compromise function. (c) Composite osteocutanous radial forearm free flap. in particular a hemimandibulectomy with or without floor of mouth reconstruction. Good results come from expert training in a centre with an interest in such reconstructive surgery and cannot be learned from a book. tongue. Although a large number of head and neck musculocutaneous flaps have been described. Reconstruction of the floor of mouth and mandible after a mandibulectomy of less than about 8–10 cm. the pectoralis major flap is now by far the most popular. Raising the flap and preparing both the donor and recipient vessels and their subsequent anastomosis are critical areas in which small errors may cause the graft to fail. The osseous portion of this free flap is very reliable but the skin less so. (d) Rectus abdominis myocutaneous free flap. One should aim to take no more than 40% of the diameter of the radius in the composite flap in order to reduce the risk of a subsequent radial fracture. The length available depends on the interval between the insertions of pronator teres and pronator quadratus. . Reconstruction following total glossectomy and reconstructing the lateral skull base after petrosectomy. lateral oropharyngeal wall. a branch of the first part of the axillary artery. It runs in a layer between the deep aspect of the muscle and its underlying fascia. A take rate of at least 90% should be obtained. this normally takes 3–4 weeks. provides good bulk and is reliable. The main disadvantage of these flaps is that the patient must submit to a twostage procedure. and for this reason the radial forearm fasciocutaneous free flap has taken over much of its previous work. This flap is based on the inferior epigastric vessels. it is important that the pedicle is not under tension when suturing the flap into position.270 OTOLARYNGOLOGY neck skin and peristomal skin. (b) Jejunal free flap. The vessels perforate the muscle to supply the overlying skin. deep fascia and muscle based on the acromiothoracic artery. Reconstruction of the floor of mouth. (e) Iliac crest osteocutaneous free flap based on the deep circumflex iliac vessels. This is a flap of skin.

Oral cavity carcinoma. Oropharyngeal carcinoma. p. p. 203. Related topics of interest Hypopharyngeal carcinoma. The repair of defects. London: Baillière Tindall. 1984.RECONSTRUCTIVE SURGERY 271 Further reading Shaheen OH. Problems in Head and Neck Surgery. 124. In: Shaheen OH (ed). . p. 197. 70–91.

neurofibroma. isoprenaline. Cushing’s disease. Sjögren originally described xerostomia. Coproxamol (dextropropoxyphene and paracetamol). Now the disease can be classified into: (a) Primary Sjögren’s syndrome (or sicca complex) consisting of xerostomia and xerophthalmia with no connective tissue component. . Myxoedema. keratoconjunctivitis sicca and rheumatoid arthritis. phenylbutazone.SALIVARY GLAND DISEASES There are four main salivary glands—two parotids and two submandibular glands—and multiple minor salivary glands which occur throughout the upper respiratory tract. 2. squamous cell carcinoma. cirrhosis. acinic cell tumour. 4. Inflammatory. Neoplasm. (b) Secondary Sjögren’s syndrome. human immunodeficiency virus (HIV). adenolymphoma. bulimia. leprosy. (a) (b) (c) (d) Benign: pleomorphic adenoma. Sjögren’s syndrome is an autoimmune disease which is characterized by periductal lymphocytes in multiple organs. Patients with enlargement of these glands or sialomegaly can pose an interesting diagnostic dilemma. notably in the oral cavity and oropharynx. xerophthalmia and a connective tissue disorder. (b) Bacterial: staphylococcal. The salivary glands are affected in approximately 40% of all cases. In one in six patients the disease will progress to a lymphoma. 5. lymphoma. coxsackie virus. with no mention of salivary gland swelling. Metabolic. which consists of xerostomia. oral contraceptive pill. thiouracil. Variable: mucoepidermoid carcinoma. tuberculosis. alcoholism. diabetes. Non-epithelial: haemangioma. echovirus. lymphangioma. (a) Viral: mumps virus. Drug induced. usually rheumatoid arthritis. Malignant: adenoid cystic carcinoma. Pathology 1. Infection. gout. actinomycosis. 3. adenocarcinoma.

Then examine the pharynx to look for a parapharyngeal lesion (in particular one arising from the deep lobe of the parotid). sebaceous cyst. Many cases are thought to be congenital. mandible tumours. duration of symptoms (benign tumours grow slowly and malignant ones fairly rapidly) and any related pain (infection. 7. Progressive destruction of the alveoli and parenchyma of the gland accompanied by duct stenosis and cyst formation. especially with cystic lesions. Specific Sjögren’s antibodies are usually also present (SSrho and SSla). Before palpating the lesion be sure to ask if it is tender. and any medication the patient is taking should be noted. the number of glands affected (tumours are unilateral apart from Warthin’s on rare occasions). Blood tests. antinuclear factor and abnormal electro-phoresis are sometimes found in Sjögren’s syndrome. Biopsy. Fine-needle aspiration biopsy is safe and often useful. lipoma and neuroma of the facial nerve. Sialectasis. this is kind to the patient and a good habit in clinical medicine—it is essential in an examination! Palpation should determine whether the lesion is local or diffuse. Tests for the relevant endocrine disorders may be appropriate. Pseudoparotomegaly. mobile or fixed and whether or not other glands are affected. 2. A plain film is useful as it may reveal a radiopaque submandibular calculus. Incisional and Trucut biopsy should not be performed as there is a risk of seeding neoplastic disease. Investigations 1.SALIVARY GLAND DISEASES 273 6. Most submandibular gland calculi are radiopaque. Radiography. The facial nerve should be tested as facial weakness also raises the suspicion of a malignant lesion. In the floor of the mouth a submandibular calculus may be felt or pressure on a parotid gland may express pus from the parotid duct. which may push the tonsil medially. Rheumatoid factor. but the results have to be interpreted in conjunction with clinical suspicion as incorrect reports are not uncommon. The history should include the age of the patient (think of mumps or congenital sialectasis). preauricular lymph node. Inspect the oral cavity and palpate all of the glands bimanually. Duct stenosis. solid or cystic. The social history including alcohol intake and risk of HIV infection may be relevant in some cases. calculus or adenoid cystic carcinoma). winged mandible. whether the swelling is exacerbated by eating (calculus disease secondary to sialectasis). History The diagnosis is often obvious from the clinical findings. A . 3. Epithelial debris or calculi may be found in the main ducts. Examination Inspect the enlarged gland and then all the other salivary glands. Inflamed skin over the swelling should make one consider an infection or skin involvement from a malignant lesion. but most parotid calculi are radiolucent. dental cyst. These disorders should be kept in mind as they may mimic sialomegaly: hypertrophic masseter. branchial cyst. calculi and sialectasis can all be diagnosed if sialography is possible. There should be a thorough review of systemic symptoms (metabolic causes). Complete the ENT examination and perform a general examination if systemic or disseminated neoplastic disease is suspected. A sialogram is probably the most useful investigation of benign salivary gland disease. MRI scanning is usually the preferred investigation in neoplastic disease to delineate any potential deep lobe involvement and to assess the tumour’s relationship to the facial nerve.

Non-neoplastic salivary gland disease. Vol. Sublabial biopsy is the definitive investigation to confirm the diagnosis in Sjögren’s syndrome (periducatal lymphocytic infiltration found). chapter 19. Related topic of interest Salivary gland neoplasms. p. . Management The management and specific treatment of the patient depends on the cause of the salivary gland swelling.274 OTOLARYNGOLOGY parapharyngeal mass should never be biopsied through the pharynx because there may be uncontrollable bleeding if the patient has a vascular lesion. Further reading Maran AGD. London: Butterworth. In: Scott-Brown’s Otolaryngology. 5. 1997. 6th edn. 274.

2. 80% of parotid tumours are benign and 80% of the benign tumours that arise in the parotid are pleomorphic adenoma. lymphoma. oral examination with particular inspection of the relevant salivary gland duct. MRI has significant advantages. A simplified classification is presented below: 1. In addition. A good approximation to remember is that 80% of all salivary tumours are in the parotid. Classification The WHO histological classification of salivary tumours now includes over 35 variants and also includes tumour-like lesions (e. salivary gland cysts). Benign. oncocytic adenoma. squamous cell carcinoma.SALIVARY GLAND NEOPLASMS Pathology Neoplastic lesions are divided into benign or malignant. neurofibroma. ductal papilloma. undifferentiated carcinoma. One in three tumours arising in the submandibular gland and one in two tumours that arise in the minor salivary glands are malignant. an excellent framework for working practice is easily established. Pleomorphic adenoma. 3. Haemangioma. peroral palpation. Radiography. acinic cell carcinoma. Adenoid cystic carcinoma. extension to the deep lobe and relation to the facial nerve. carcinoma expleomorphic adenoma. Clinical assessment All patients with a mass in a salivary gland should have: an inspection and palpation of the mass itself. and malignant lesions can be primary or secondary. Using . Investigations 1. Non-epithelial. adenocarcinoma. CT scanning of a parotid tumour is useful in the assessment and delineation of anatomical structures.g. Salivary gland tumours are no exception in this respect. monomorphic adenoma. Warthin’s tumour (papillary cystadenoma lymphomatosum). if one can remember the epithelial and the non-epithelial histology of the organ. Mucoepidermoid carcinoma. lymphangioma. Malignant. facial nerve assessment and neck node palpation. inspection of the oropharynx for parapharyngeal extension assessment. except that some such neoplasms have variable biological behaviour. Variable. 4.

2. They are soft and cystic tumours which are thought to arise from heterotopic parotid tissue in the lymph nodes within the parotid gland. and thus non-diagnostic. delineating the facial nerve and in identifying the tumour edge. However. 4–6 cm in diameter. 3. and/or extraparenchymal extension (but not facial nerve). > 6 cm in diameter. without extraparenchymal extension. Monomorphic adenomas arise from ductal epithelium and are treated by surgical excision with a cuff of tissue.276 OTOLARYNGOLOGY STIR sequencing appears to add to the sensitivity in detecting lesions of the parotid gland. causing recurrence. Management of recurrent tumour is difficult as the facial nerve may be involved and its sheath may need to be stripped. Pleomorphic adenoma is the commonest benign salivary tumour. The peak incidence is the seventh decade and the male-female ratio is 7:1. has few complications (seeding of the tumour does not appear to occur) and may prevent an ill-advised and often ill-fated incisional or excisional biopsy of a parotid mass. . It has a pseudocapsule of compressed parotid tissue into which the tumour usually has many protuberances. Proponents of the technique argue that FNA provides diagnostic information which may allay a patient’s anxiety and aid in preoperative counselling and planning of surgery. 2–4 cm in diameter. Ten per cent are bilateral. unlike pleomorphic adenoma. If the capsule is ruptured during removal. and/or base of skull or facial nerve invasion. Treatment is by excision and. Microscopically it comprises epithelial and mesodermal elements with a mucopolysaccharide stroma giving rise to a characteristic mixed staining pattern. Fine-needle aspiration biopsy (FNA). They are therefore excised with as large a margin as possible to reduce the risk of capsule rupture. The stage of the disease has been shown to be a more important prognostic parameter than its histological grade. in whom the aspirates often yield straw-coloured fluid. It arises from intercalated duct cells and myoepithelial cells. 2. < 2 cm in diameter. This is particularly true in patients with cystic lesions of the parotid. rarely radical surgery is needed with resection of the facial nerve. which is almost invariably hypocellular or acellular. soft tissues). Many surgeons advocate adjuvant postoperative radio-therapy in these situations. Staging With malignant tumours of the parotid gland. without extraparenchymal extension (skin. those against the routine use of FNA argue that one cannot rely on the sensitivity or specificity of the procedure. then tumour may implant. usually seen in elderly men. Superficial parotidectomy or hemisuperficial parotidectomy when the lesion is small is now the preferred procedure. Warthin’s ‘s tumour (papillary cystadenoma) is a benign tumour. but rarely synchronously. A tumour of any size with significant local extension. The UICC system is summarized below: T0 T1 T2 T3 T4a T4b No clinical evidence of tumour. If the result of FNA is at variance with other findings then clinical judgement should prevail. The sex distribution is equal and the peak age incidence is in the fifth decade. a significant correlation exists between tumour stage and survival. Benign tumours 1. recurrence almost never occurs. FNA is a relatively painless procedure. The role of FNA in the diagnosis of benign and malignant salivary gland disease is a controversial issue. The facial nerve should if at all feasible not be sacrificed.

Postoperative radiotherapy will not affect the graft. however. 1993. 1993. Low-grade or well-differentiated tumours usually behave in a benign fashion. Radiotherapy in the curative and palliative treatment of patients with adenoid cystic carcinoma of salivary gland origin is useful in some cases. Wilson J (ed). but is more common in minor than in major salivary glands. the behaviour is not always accurately predicted by the histological appearance. Current Opinion in Otolaryngology and Head and Neck Surgery. The sex incidence is equal and they are seen most often in patients in their sixth decade. 2000. Related topic of interest Salivary gland diseases. If the facial nerve is free of tumour it may be dissected out and left intact. Effective Head and Neck Cancer Management. It is usually found in the superficial lobe of the parotid.SALIVARY GLAND NEOPLASMS 277 4. The patients often complain of facial pain and may present with a facial paresis. Tumours with variable behaviour 1. The tumour is slow-growing and tends to spread along nerve sheaths. . it is often involved. intermediate ones are more aggressive and high-grade or undifferentiated tumours metastasize early and carry a poor prognosis. regarding them as high-grade mucoepidermoid tumours. It is the commonest salivary neoplasm in children. Caslin AC. but is still being assessed. Journal of Laryngology and Otology. Adenoid cystic carcinoma is the commonest malignant tumour and may arise from any salivary tissue. They are. The sural nerve is preferred as the greater auricular nerve may be involved and should also be excised. Acinic cell carcinoma is similarly difficult to classify. true malignant pleomorphic adenomas are rare. 2. Squamous cell carcinoma. However. Some pathologists doubt their existence. and in this situation it needs wide excision and anastomosis with a nerve graft. 271. British Association of Otolaryngologists. Second Consensus. p. Mucoepidermoid carcinoma arises in any salivary tissue but predominantly the parotid gland. However. 2. Treatment is usually by radical excision and adjuvant radiotherapy. 1: 91–96. much more benign than mucoepidermoid tumours. Oncocytoma is a benign eosinophilic tumour (also called oxyphil adenoma) that arises from intralobular ducts or acini. Malignant tumours 1. Salivary gland tumours. Head and Neck Surgeons. Roland NJ. Further reading Medina JE. Adenocarcinoma accounts for about 3% of parotid tumours and 10% of submandibular and minor salivary gland tumours. Fine needle aspiration cytology of salivary gland lesions reported immediately in a head and neck clinic. 3. Jones AS. 107:1025–1028. The incidence of lymph node metastases is low and distant metastases occur late. It can undergo malignant change and treatment is also by excision with a cuff of tissue.

Infection (Syphilis. 2. adenocarcinoma. usually as a complication of septal surgery. Drugs (cocaine. chronic relapsing polychondritis). The severity of the symptoms depends on the position and the size of the perforation. polyarteritis nodosa. Aetiology 1. Idiopathic. In any patient where there is uncertainty about the cause. which normally involves the bony septum. Neoplasm (Squamous cell carcinoma. Inflammatory (Wegener’s granulomatosis. nasal cautery). particularly when the Killian incision is used. Most perforations are iatrogenic in origin. crusting and nasal obstruction. Septal perforations are usually preceded by ulceration except when following a septal haematoma or septal abscess. Investigations The history will very often give the diagnosis.SEPTAL PERFORATION Perforation of the nasal septum is most common in the anterior cartilaginous part except for that caused by syphilis. arsenic. The main complaints are recurrent epistaxis. 5. 3. the following tests should be performed: . chrome. Self-inflicted (nose picking). T-cell lymphoma). The larger the perforation and the more anterior its position. Trauma. systemic lupus. alkaline dusts). latrogenic (SMR. A very small perforation may cause whistling on nasal breathing. Many septal perforations that were previously considered to be idiopathic are now thought to be secondary to nose picking. Inhalation of irritants. 6. sport injury). Injury (assault. snuff). Clinical features The majority of perforations are asymptomatic. dryness in the nose. basal cell carcinoma. Occupational (hexavalent. tuberculosis). 4. road accident. septoplasty. the worse the symptoms.

Many perforations are asymptomatic and informed reassurance is all that is required. Vol. ANCA for Wegners.SEPTAL PERFORATION 279 • Blood tests should include an FBC. If the perforation continues to trouble the patient it is worth trying to plug the hole with a silastic septal button. Follow-up and aftercare This will depend on the cause of the perforation. In: Mackay IS. Related topic of interest Nasal trauma. perforations that cause a whistle can be treated by enlarging them. Treatment is usually indicated when there is troublesome crusting or bleeding. Medical treatment with 25% glucose in glycerol drops will loosen and help clear crusts. Surgical closure of the perforation is difficult to achieve. septal mucoperichondrial flaps. FTA for syphilis. buccal mucosa or sublabial myomucosal flaps. The nasal septum. 177. 4. London: Butterworth. Barrier creams can help prevent drying and crusting. Scott-Brown’s Otolaryngology. composite grafts from the pinna and moving septal cartilage to fill the hole have all been described. the severity of the symptoms and the particular treatment the patient has been given. Silver nitrate cautery can be applied to bleeding granulations. A variety of operations including the use of split-skin grafts. ESR. Wegener’s granulomatosis or metastases. Further reading Brain D. • A chest radiograph may show lesions in tuberculosis. 6th edn. A patient with a silastic button should be seen at regular 4–6-monthly intervals to decrust and clean the prosthesis. 1997. Paradoxically. Bull TR (eds). • Urinalysis (haematuria or proteinuria may result from nephritis in Wegener’s granulomatosis or polyarteritis). • A biopsy from the edge of the perforation if there is suggestion of a neoplasm or granuloma. Treatment The first objective is to cure the causative disease process before specific treatment of the perforation. p. .

Epithelial (papilloma. 10% lymphomas and about 4% adenocarcinomas. Benign. chondroma.SINONASAL TUMOURS Tumours of the sinonasal region comprise a diverse group of benign and malignant neoplasms. 1. anaplastic carcinoma. nasal glioma. The male: female ratio in series varies between 1:2 and 1:5. It is about double this in Arabs. Human papilloma virus genome has been identified and therefore implicated as an aetiological agent in non-dysplastic and dysplastic inverted papilloma and squamous cell carcinoma. Histologically 50% are squamous cell carcinoma. adenoma and inverted papilloma). the Japanese and Africans. Half of sinonasal cancer arises from the upper jaw. Non-epithelial (fibroma. adenocarcinoma. Their low incidence and the lack of a consensus regarding staging has made comparison of treatment regimes between centres difficult. Workers handling chromate salts and those involved in nickel refining are at an increased risk of nasal malignancy. and fibroosseous tumours. Malignant Epithelial (squamous cell carcinoma. a quarter from the ethmoids and a quarter from the nasal cavity. haemangiopericytoma. malignant melanoma. transitional cell carcinoma. The association between the ethmoidal adenocarcinoma and hardwood workers is well documented. Chronic nasal pathology. chordoma. The latter constitute a considerable challenge to the head and neck surgeon as they often present with advanced disease. Pathology About 10% of head and neck cancer is sinonasal with an incidence in the UK and the USA of about 10 per million. salivary gland malignancy in particular adenoid cystic carcinoma and olfactory neuroblastoma. and smoking cigarettes have recently been implicated as providing an increased risk of squamous cell carcinoma. Schwannoma. Classification Both benign and malignant groups can be classified into epithelial. non epithelial. Immunocytochemical analysis (in particular neurone specific enolase) of the small cell cancers (anaplastic and lymphomas) will reveal a proportion to be olfactory neuroblastomas. odontogenic. . including sepsis and Wegener’s granulomatosis. haemangioma. 2. meningioma and osteoma). 15% anaplastic.

chondrosarcoma. Five per cent of subjects will have a metastatic neck lymph node. All ages are affected and urine vanillylmandelic acid (VMA). most commonly the bronchus. originally described by Ringertz. the precursors of olfactory cells.SINONASAL TUMOURS 281 Non-epithelial (fibrosarcoma. Probably less than 2% undergo malignant change although there may be a synchronous sinonasal squamous cell carcinoma in up to a further 10%. Malignant melanomas comprise 1% of sinonasal carcinomas and usually arise from the septum or lateral nasal wall. where the prognosis is reasonable. Further delays may arise because these symptoms are not usually associated with carcinoma by primary care physicians. . This may include the cheek. High grade T cell lymphoma (formerly lethal midline granuloma): see Related topic Non-healing nasal granulomata. angiosarcoma. This indicates a poor prognosis but not necessarily incurability. nasal cavity and anterior cranial fossa. superiorly where they may erode the cribriform plate or posteriorly to erode the posterior wall of the frontal sinus and impinge on frontal lobe dura. Osteomas most commonly arise from the frontal region where they may expand medially to block the frontal recess predisposing to a secondary mucocele or frontal sinusitis. Frontoethmoidal and antral malignant melanoma have a much worse prognosis. and osteogenic sarcomas). on presentation. with a propensity to recur many years after apparent cure. nasal obstruction and headaches occur only with a significant tumour mass. Malignant sinonasal tumours Squamous cell carcinoma and adenocarcinoma both usually present at an advanced stage because their presenting symptoms of epistaxis. inferiorly to displace the orbit. usually upper deep cervical. is the most important of this group forming about 5% of all nasal tumours. Haemangiopericytomas may arise anywhere in the sinonasal region and have a spectrum of aggression. A quarter of patients will die from distant metastases. and microscopically resembles other small cell malignancies such as high grade lymphoma and anaplastic carcinoma. Macroscopically there is usually a papilliferous exophytic mass. It always involves the cribriform plate so if resection is contemplated this must be via a craniofacial approach. is not usually detectable. with microcyst formation. rhabdomyosarcoma. Cheek swelling occurs only when the tumour has breached the anterior antral wall to impinge on periosteum. It is usually impossible to define a site of origin of the carcinoma due to its diffuse extent. There is no relationship between Clark’s classification (penetration of specific skin layers) and prognosis in this region although the latter is associated with Breslow’s classification (thickness of the lesion in mm). This emphasizes the need for careful nasendoscopic follow up. Olfactory neuroblastomas were undoubtedly under reported until recently when immunocytochemical stains for this tumour became available. The epithelium retains its basement membrane. Adenoid cystic carcinoma is particularly difficult to eradicate because of its ability to spread via the branches of the trigeminal and olfactory nerves along perineurium. It arises from neural crest stem cells. Important benign sinonasal tumours Inverted papilloma. Microscopically there are deep invaginations of epithelium into the stroma. They consist of hard cortical bone and require excision if symptomatic or enlarging. orbit.

except for the posterior wall.. T4 Tumour invades orbital contents beyond the floor or medial wall including apex and/or any of the following: cribriform plate. Epistaxis. Nasal cavity tumours. including extension into the hard palate and/or middle nasal meatus. T1 Tumour limited to the antral mucosa with no erosion or destruction of bone. Ethmoid sinus. T1 T2 T3 T4 Tumour confined to ethmoid with or without bone erosion. base of skull. sphenoid sinus. . nasal obstruction and if the lamina papyracea is breached. Features are similar to frontal osteomas except the history is shorter and more rapidly progressive. subcutaneous tissues. nasopharynx. retained secretions and fat. Epistaxis. Tumour extends to anterior orbit and/or maxillary sinus. skin of cheek. Oroantral fistula. No evidence of primary disease. Epistaxis. Tumour with intracranial extension. Maxillary sinus. A T2 weighted or STIR sequence MRI scan may distinguish tumour from inflammation. epiphora and diplopia.282 OTOLARYNGOLOGY Staging The UICC staging is as follows: Tx T0 Tis Primary tumour cannot be assessed. 3. trismus and ethmoidal symptoms occur with advanced disease. Tumour extends into nasal cavity. involving sphenoid and/or frontal sinus and/or skin of nose. nasal obstruction. Ethmoidal. 2. T2 Tumour causing bone erosion or destruction. nasal obstruction and a mass visible on nasendoscopy. frontal sinus. Nasendoscopy may reveal tumour extruding from the middle meatus. Antral. 4. floor of medial wall of orbit. T3 Tumour invades any of the following: bone of posterior wall of maxillary sinus. orbital extension including apex. proptosis. cheek swelling. headache if blocking the osteomeatal complex and atypical facial pain (suggesting involvement of the pterygopalatine fossa or the infra orbital nerve). Investigations A high definition CT scan on both bone and soft tissue windows is the ideal to show soft tissue and bone involvement. Bone does not generate a signal. Frontal sinus. Clinical features 1. Carcinoma in situ. ill-fitting dentures.

Recent studies have demonstrated recurrence rates no higher than with external approach surgery. The accurate identification of disease extent with CT and MRI imaging has allowed the advent of endoscopic resection for inverted papilloma. Recent work has also shown its application for tumours involving the posterior ethmoids and anterior wall of sphenoid. Tumour limited to the anterior ethmoids or isolated middle turbinate or middle meatal lesion are ideal for endoscopic resection. The technique allows direct visualization of tumour and its extent can be accurately identified during surgery. (b) Total maxillectomy. Follow-up which involves nasendoscopy to inspect the surgical cavity created or direct inspection of a maxillectomy cavity after obturator removal. 2. Limitations of the endoscopic approach include tumour extending into the frontal sinus and anterior wall of maxilla. There are three main surgical options for carcinoma: (a) Lateral rhinotomy for tumour limited to the lateral nasal wall. Prognosis by stage is difficult for reasons already outlined. quarterly for the third and six-monthly until five years post surgery. Follow-up and aftercare Ideally an orthodontist should take an impression of the maxillectomy cavity at operation in order to make a temporary obturator. For antral carcinoma. Post-operatively endoscopic inspection of the surgical cavity allows accurate monitoring of patient progress and early identification of recurrence. well fitting and easily removable obturator. there is less blood loss and the hospital stay is shorter. Some surgeons thereafter review annually for a further five years. Further review allows a fine tuning of the prosthesis to provide a light. Reconstruction is by primary closure where possible. Adjuvant radiotherapy may be indicated depending on tissue margins. but have the disadvantage that they may mask an early recurrence. Overall a five-year survival of 40–50% would be reasonable. laryngopharyngeal examination to exclude a second primary and neck examination to look for metastases should be monthly for the first post-operative year. It prevents an external scar. nasal cavity and ethmoid. Extensive experience and a high level of expertise in endoscopic sinus surgery is a prerequisite to undertaking the endoscopic approach. Wigand’s figures for disease of similar extent are 17% recurrence rate for the endoscopic approach and 19% for external approach surgery at 2 years followup. In essence provided the endoscope can visualize the distal extent of tumour during surgery then endoscopic resection is a reasonable and perhaps preferred alternative to external approach surgery. Inverted papilloma. In general an orbital exenteration is indicated only if tumour breaches periostium to involve orbital fat. . Only the surgeon should extract crusts from the nares of the craniofacial patient as these may be attached to a fascia lata or temporalis fascia graft overlying the anterior cranial fossa. (c) Craniofacial resection is indicated when the cribriform plate is involved or breached. Draf quotes a recurrence rate of 9% by the endoscopic approach. Split thickness skin grafts should line the exenteration cavity. Glycerine and glucose nose drops and regular douching with saline will minimize this.SINONASAL TUMOURS 283 Treatment 1. Carcinoma. Free flaps or a temporalis muscle swing flap will fill in the cavity and produce the optimum cosmetic result. An upper limb extension will allow tumour limited to the frontal ethmoidal region to be accessed. There is significantly less morbidity by the endoscopic approach. comfortable. Those who have a lateral rhinotomy or craniofacial cavity often have excessive crusting in the early post-operative phase. bimonthly for the second.

Donald PJ. Current Opinion in Otolaryngology and Head and Neck Surgery. Cheesman AD. British Association of Otolaryngologists. The treatment of inverted papilloma. Harrison DFN. Wilson J (ed). Related topic of interest Nasal granuloma. 7:33–39. Brors D and Draf W.284 OTOLARYNGOLOGY Further reading Lund VJ. 1997. American Journal of Surgery. Second Consensus. Head and Neck Surgeons. 1999. p. 1988. Craniofacial resection for tumors of the nasal cavity and paranasal sinuses. . Lund VJ. 1989. 170. Lloyd GAS. Magnetic resonance imaging of paranasal sinus tumors for craniofacial resection. Head and Neck Surgery. 5: 73–78. 2000. Howard DJ. Management of sinus malignancy. 11:279–283. Current Opinion in Otolaryngol and Head and Neck Surgery. 156:187–190. Effective Head and Neck Cancer Management.

• Nasal tumour. tobacco smoke). cystic fibrosis). General. Immunocompromised host. abnormal uncinate process. • Fractures involving the sinuses. Local. common cold or influenza.SINUSITIS Predisposing factors The commonest causes are nasal. Both the maxillary and frontal sinuses drain through narrow spaces and interstices into the middle meatus. • Nasal polyps. tonsillitis or adenoiditis). The ethmoids also drain into this and the superior meatus. thus predisposing to consequent infection. • Nasal foreign body. i. Any condition narrowing or blocking these may lead to secretion retention and poor ventilation. etc).e. The maxillary sinus is clinically the most commonly affected. frontal and sphenoid sinuses in that order. • Dental extraction or infection (diseases of the upper premolars and molars). 2. Kartagener’s syndrome. . fumes. • Pre-existing rhinitis (allergic. • Upper respiratory tract infection (acute infective rhinitis. • Nasal anatomical variations (septal deviation. middle turbinate or ethmoid bulla) narrow the infundibulum and predispose to its occlusion when there is intercurrent disease.g. • • • • Debilitation. Acute sinusitis Acute inflammation of one or all the sinuses may occur (pansinusitis). Atmospheric irritants (dust. vasomotor. 1. rhinitis medicamentosa. Mucociliary disorders (e. • Swimming and diving. followed by the ethmoid.

Haemophilus influenzae (pneumococcal and haemophilus infections accounting for 70% of cases in adults). Sphenoid infection may produce retro-orbital pain. The usual causative organisms are Streptococcus pneumoniae.286 OTOLARYNGOLOGY Pathology The majority of cases follow a viral upper respiratory tract infection which involves all of the respiratory epithelium including the paranasal sinuses. Radiological investigation may show an opacity or fluid level. suggesting a dental origin of maxillary sinusitis. Temporal arteritis. and Staphylococcus aureus. Dental pain. Investigations An elevated white cell count and erythrocyte sedimentation rate (ESR) will confirm an acute infection. . Ethmoid sinusitis may cause pain between the eyes accompanied by frontal headache. malaise and possibly a pyrexia. Pain developing in the cheek or upper teeth indicates maxillary sinus involvement. which blocks the ostia. When there is doubt about the diagnosis. nasal congestion. Anterior rhinoscopy may show red oedematous nasal mucosa and turbinates. Herpes zoster. Percussion over the upper teeth may elicit tenderness. Such infections cause hyperaemia and oedema of the mucosa. leading to stasis of secretions predisposing to secondary bacterial infection. Endoscopy with a 0° or 30° scope may reveal pus in the middle meatus or sphenoethmoidal recess. Escherichia coli and Streptococcus faecalis may spread from a dental source. Frontal sinusitis produces pain in the forehead and tenderness below the eyebrows. Klebsiella pneumoniae. Acute fungal infections (for example mucormycosis and aspergillosis) are rare. Erysipelas. The fullness in the face and pain may be exacerbated by bending forward or stooping down. Sinonasal tumour. The infection will also paralyse the cilia. Specific features may indicate the sinus that is infected. but may develop in immunocompromised or elderly diabetic patients. or pain anywhere across the vault. The patient will have pain over the infected sinus. Moraxella catarrhalis. Clinical features The symptoms usually occur several days after developing an upper respiratory tract infection. It may also be possible to elicit tenderness over the infected sinus. Differential diagnosis • • • • • • • Migraine. Trigeminal neuralgia. ideally using both soft-tissue and bone window settings. Where possible pus from the nose should be cultured and blood cultures should be taken if there is systemic upset. although plain X-rays are rarely if ever used (see Radiology). There will be cellular infiltration and an increase in mucus production. fullness in the face. Streptococcus pyogenes. further confirmation can be obtained by a high-definition coronal CT scan.

g. co-amoxyclav. clarithromycin). Functional endoscopic sinus surgery (see p. Any pus obtained should be cultured. A second generation cephalosporin (e. nasal discharge. the incidence of sinusitis has increased. The decongestant may reduce nasal oedema. pseudoephedrine or xylometa-zoline). hygiene. Figures from the USA however. and hopefully open the natural ostia of the sinuses to allow free drainage. If the patient has suffered recurrent infections it may be appropriate to perform an intranasal antrostomy for better and longer-lasting drainage. and aid infundibular drainage. and the introduction of antibiotics. The patient should be reviewed after resolution of the acute phase. The current practice of many rhinologists is to shrink the mucosal lining. It may be necessary to perform repeat antral washouts for some patients. This will not only treat any infection in the maxillary sinus but will also promote drainage from the other sinuses. then the patient may need antral puncture and washout.g. This is best performed with the aid of an endoscope. The changes in the mucosa over .g. Medical treatment In the acute stages the patient should have: • Bed rest and adequate simple analgesia (e. Those surgeons who follow the philosophy of functional endoscopic sinus surgery claim that if definitive endoscopic sinus surgery is performed in the acute phase no further washout should be necessary. It has been stated that the incidence of this problem in the UK has been reduced by improvements in the general health of the population. postnasal drainage. endoscopy) persist for weeks to months. • Broad-spectrum antibiotic (e. 108) is now considered to be the treatment of choice. septoplasty for septal deviation) should be organized.SINUSITIS 287 Management The aims of treatment are to resolve and limit the course of the acute infection. Ulceration of the epithelium will result in the formation of granulation tissue. It is usually considered to be a condition in which sinusitis symptoms (congestion. Pathology There is an increase in vascularity and vascular permeability. but in some cases the onset is more insidious.g. If acute sinusitis fails to respond to medical treatment. cefuroxime) is recommended for penicillinresistant pneumococci. Frontal sinu-sitis which does not respond to these measures may requires trephine of the floor of the sinus via a small incision above the medial canthus. The patient should have a full 7-day course of the antibiotic. There is no consensus view on what constitutes chronic sinusitis. diet. Chronic sinusitis accounts for over 85% of all clinic visits for sinusitis in adults. 2. Goblet cell hyperplasia and a chronic cellular infiltrate will occur. Chronic sinusitis Chronic inflammation of the sinuses usually follows recurrent acute sinusitis. The ethmoid sinuses can be uncapped to promote drainage if they are specifically diseased and an anterior sphenoidotomy may be necessary for acute sphenoiditis. to prevent complications and to correct any precipitating factor. • A decongestant (e. Correction of any obvious precipitating factor (e. Multiple small abscesses occur in the thickened mucosa and fibrosis of the submucosal stroma supervenes. Surgical treatment. It can be given locally or systemically. by placing a pledget of cocainized cotton wool into the middle meatus for 20 minutes. 1. paracetamol). This leads to oedema and hypertrophy of the mucosa which may become polypoidal.g. facial pain) and signs (CT. confirm that over the past decade.

for example rhinitis or nasal polyps. Chronic pharyngitis and laryngitis with the patient complaining of a productive cough are often encountered. 1. such as inflammatory disease. to ventilate the sinus and to restore normal mucosal lining in the sinus. A headache over the forehead. This does not rule out a sinus cause for their problem. Surgery (a) Functional endonasal sinus surgery. and when the original cause of infection has been treated the lining will not revert to normal. (b) Those with headaches clearly traceable to non-sinus causes such as migraine. optic nerve or dura is less likely. Plain sinus radiographs are rarely indicated now because they may show varying degrees of opacification of the involved sinuses with mucosal thickening. Clinical examination will usually show nasal inflammation or perhaps another obvious intranasal predisposing factor. One modality is said to enhance the accuracy of the other. some patients with sinogenic headaches may present with an atypical history and have negative findings on examination and plain sinus radiographs. neoplasm. the bridge of the nose and the face is common. Functional endoscopic sinus surgery is now the preferred alternative to the classical open surgical approaches to chronic sinusitis.g. temporomandibular joint diseases. because different patient inclusion criteria may affect study results. Differential diagnosis It is not uncommon for general practitioners and those in other specialties to ascribe facial pain and headaches to sinus disease. A course of broad-spectrum antibiotics in combination with a decongestant should be tried initially (though they should be avoided long-term). Investigations Only the combination of diagnostic endoscopy and high-definition coronal section CT scanning will provide the maximum information. Step-wise removal of the ethmoidal cells extending to the posterior ethmoid and sphenoid sinus . Furthermore. The ENT surgeon is confronted as a rule with three different groups of headache patients: (a) Those with headaches clearly connected to a sinus problem. glaucoma. barotrauma or another readily identifiable cause. (c) Those whose problems are not clear and in whom there seems to be no overt indication of sinus disease. a steroid nasal spray. Chronic irritation of the nasal airway and repeated rubbing may lead to a vestibulitis and epistaxis. hypertension. The cardinal symptoms are nasal congestion.288 OTOLARYNGOLOGY this time may be irreversible. 2. The patient may also suffer with anosmia. In this group of patients nasendoscopic examination with a high-definition coronal section CT scan may confirm that the symptoms are indeed sinus related. often when it is not. especially in infections of dental origin. The principal aims of treatment are to correct the predisposing cause. Any obvious predisposing factor. It has been suggested that chronic paranasal sinus pain alone should not constitute chronic sinusitis. oral course of steroids). Those who advocate this procedure claim that more accurate surgery can now be undertaken and that injury to the eye. Medical. nasal or postnasal discharge and pain. antihistamines. cervical spine disorders. neuralgias. should be treated with medical therapy (e. or even cacosmia (unpleasant smell). Mucosal thickening occurs in 30% of individuals and its detection is often meaningless. The definition of chronic sinusitis becomes important in comparing studies on the disease.

chemotherapy patients. (b) Open sinus surgery procedures. • Chronic frontal sinusitis: external frontoethmoidectomy (Howarth’s operation). This should be suspected in a healthy patient presenting with chronic sinusitis resistant to conventional therapy. The natural ostium of the maxillary sinus in the middle meatus can be cleared. Patients are typically immunocompetent and non-atopic. Treatment is by endoscopic removal of debris and ventilation of the sinus. Because of the potential for orbital and intracranial complications. • Chronic maxillary sinusitis: Caldwell-Luc procedure. Typically occurs in atopic immunocompetent young adults. Systemic steroids and antifungal therapy (itraconazole). The disease still carries a mortality rate of 50–80%. . Allergic fungal sinusitis. the better the prognosis. as can any disease of the frontonasal duct. A rare entity that occurs in immunocompromised individuals (diabetic ketoacidosis. may also be useful. Associated fungi include Aspergillus. If irreversible changes have occurred to the sinus mucosa then some surgeons would consider it necessary to remove it. the more radical open procedures are still used and asked about in the examinations. Aspergillus fumigatus is the most common organism isolated. so the choice of operation should be tailored to the requirements of the individual patient. Mucor and Rhizopus are the associated organisms. 2. Mycetoma. osteoplastic flap procedure (MacBeth’s operation). Chronic indolent sinusitis. because of advances in diagnostic techniques (nasal endoscopy and CT scans) and increasing numbers of immunocompromised individuals. transantral to the posterior ethmoids then to the sphenoid sinus. opened and enlarged. Immediate treatment consists of intravenous antifungal therapy (amphotericin B) and radical surgical debridement. Bipolaris and Curvularia. Aspergillus fumigatus is the most common organism isolated. This is a slow progressive disease characterized by granulomatous infection. via an external frontoethmoidectomy. These are masses of fungal debris that usually occur in the maxillary or ethmoid sinuses.SINUSITIS 289 can be undertaken. Usually associated with nasal polyps and asthma. appropriate treatment needs to be rapidly instituted. but details of each procedure and its complications should be sought from an operative textbook. which can extend to a total maxillectomy and orbital exenteration. The earlier the treatment is started. AIDS. Surgical debridement with removal of all debris from the sinuses is required. Fungal sinusitis This is now being recognized more frequently. external ethmoidectomy (Patterson’s operation). Fungal sinusitis can be divided into the following entities: 1. 3. Each procedure has its own limitations and specific complications. A wide range of procedures are available. Acute invasive (fulminant) sinusitis. Amphotericin B is the drug of choice. However. The mainstay of therapy is polypectomy and aeration of the sinuses. Aspergillus. transantral (Horgan’s operation). • Chronic sphenoiditis: via an intranasal ethmoidectomy. They are listed below. There is usually no requirement for antifungal or any other systemic therapy. leukaemia and lymphoma). • Chronic ethmoid sinusitis: intranasal ethmoidectomy. 4.

131.290 OTOLARYNGOLOGY Further reading Durand M. Current Opinion in Otolaryngology and Head and Neck Surgery. Intrinsic rhinitis. Related topics of interest Allergic rhinitis. 5:8–12. p. Stammberger H and Wolf G. 1997. Sinusitis— complications. Rhinology and Laryngology. The antibiotic treatment of sinusitis. p. Annals of Otology. . p. 291. 1988. p. 108. 11. 97 (Suppl. Functional endoscopic sinus surgery. Headaches and sinus disease: the endoscopic approach. 134).

visual fields. Orbital complications These can occur at any age. otitis media). cavernous sinus thrombosis). An external ethmoidectomy is performed and a drain inserted. A CT scan will confirm the collection and extent of the disease. Synchronous infection of the maxillary sinus may require treatment with intravenous antibiotics and surgical drainage (usually an endoscopically fashioned middle meatal antrostomy and sinus washout). but are most frequent during an acute exacerbation of chronic sinusitis. Elevation of the orbital periosteum usually reveals the pus under pressure. Locoregional complications (pharyngitis. intracranial abscess. Peri-orbital cellulitis and orbital abscess usually result from direct spread of pus from the ethmoid sinuses. pupillary reflexes. The ethmoids are separated from the orbit by the thin lamina papyracea. Visual acuity. The biggest anxiety is the risk of blindness as a result of tension and septic necrosis of the optic nerve. If the other eye is stimulated but there is no contralateral reflex. Mucocele. With an orbital collection the eye will become proptosed and its movements progressively restricted to a complete ophthalmoplegia. Absence of the ipsilateral and contralateral light reflex will occur with visual impairment. Complications may follow an acute infection. They can be divided into: • • • • • Orbital complications (orbital cellulitis and orbital abscess). Osteomyelitis (maxilla or frontal bone). Early liason with an ophthalmologist is recommended. red-green colour vision. The swelling may displace the orbit lateral and down. Colour blindness is an early sign. Urgent surgical drainage is indicated. Cellulitis requires treatment with intravenous antibiotics and nasal decongestants to resolve the infection and limit further spread. A subperiosteal abscess results from direct spread from the ethmoids and collects between the lamina papyracea and the orbital periosteum. An incision is made in the superomedial aspect of the orbit. but are more common in children. then the third cranial nerve (occulomotor) will have been affected. The orbital septum forms a natural barrier which may localize the infection anteriorly as a preseptal cellulitis or posteriorly as orbital cellulitis.SINUSITIS—COMPLICATIONS In most cases sinusitis is uncomplicated and spread of infection beyond the walls of the sinus is uncommon. Aching around the orbit is followed by oedema of the eyelids and later the conjunctiva. laryngitis. Intracranial complications (meningitis. and the optic disc should be examined. . It can also spread from thrombophlebitis of mucosal vessels in any of the sinuses.

These features can be dramatic if infection supervenes (pyocele). An endoscopic approach is an alternative in experienced hands. Intracranial complications should all be treated with high-dose intravenous antibiotics. It occurs most commonly in the frontal sinus. ethmoidal and sphenoid sinuses are closely related to and separated by a thin wall of bone from the anterior cranial fossa. There is a build-up of dull local pain with oedema of the forehead and the upper eyelids. The main complaints are headache and swelling. CT scans will further delineate the extent of the disease if needed. This is a life-threatening condition with a high risk of intracranial complications. Treatment comprises intravenous antibiotics and debridement when necessary. High resolution CT scan and MRI will illustrate the extent of the problem. Treatment is surgical evacuation and drainage of the sinus. Mucocele A mucocele may develop when the outlet from a sinus becomes permanently blocked.292 OTOLARYNGOLOGY Osteomyelitis This only occurs in diploic bone and thus only in the maxilla of children and the frontal sinus of adolescents and adults. The mortality and morbidity after intracranial complications is considerable. IV. subdural or cerebral) and cavernous sinus thrombosis may complicate sinus infections. A CT scan with enhancement or MRI scan may assist in diagnosis. Intracranial complications The cavities of the frontal. There is an accumulation of sterile mucus which becomes increasingly viscous. and appropriate debridement is required. Cavernous sinus thrombosis will cause a high fever. Meningitis is the commonest complication. maxillary and sphenoid sinuses can all be afflicted. The common organism is Staphylococcus aureus. the two options in common use are external fronto-ethmoidectomy (Howarth’s operation) and the osteoplastic flap procedure (Macbeth’s operation). The cyst gradually expands and exerts pressure on the sinus walls causing erosion. Infection may involve the brain and meninges from either direct spread or retrograde thrombophlebitis. A lumbar puncture may identify the causative organism. together with drainage of the offending sinuses by an ENT surgeon. particularly in sinusitis patients who become drowsy or show some neurological deficit. but encephalitis. but it is essential to exclude raised intracranial pressure before this is done by looking for papilloedema. An intracranial abscess may be more difficult to diagnose. The clinical features of meningitis are well known. To approach the frontal sinus. Prompt treatment with high doses of intravenous antibiotics. ophthalmic and maxillary branches of V and VI). Diplopia and proptosis may result if the mucocele expands into the orbit. It presents as a painful swelling of the cheek and lower eyelid. The important point is that the ENT surgeon should always maintain a high index of suspicion for all intracranial complications. especially the orbit. A subperiosteal abscess of the forehead may form (Pott’s puffy tumour). intracranial abscess (extradural. Osteomyelitis of the maxilla is rare and usually only seen in third world countries. Up to 25% of patients may die and nearly a third of surviving patients will suffer with epilepsy. The eyes will proptose and an ophthalmoplegia of the cranial nerves which travel in the cavernous sinus will occur (III. surgical drainage of the frontal sinus. This leads to displacement of adjacent structures. An extradural or subdural abscess will require drainage by a neurosurgeon. Osteomyelitis of the frontal bone is more extensive and dangerous. . reduced conscious level and cerebral irritation. but the ethmoid. Radiographs will show enlargement of the sinus with thinning of the bone.

1–11. . In: Diseases of the Head and Neck. Further downward spread may lead to irritation of the vocal cords causing a laryngitis. Further reading Lund VJ. Mucopus from sinusitis is carried back through the nasal airway into the pharynx and may cause a pharyngitis. Functional endoscopic sinus surgery. Sinusitis is also implicated as a cause and complication of tonsillitis and otitis media.SINUSITIS—COMPLICATIONS 293 Locoregional complications Regional complications occur as a result of infection and inflammation spreading through the rest of the upper aerodigestive tract mucosa. 108. Vol. Invasion of the subepithelial lymphoid tissue will produce a granular pharyngitis with visible nodules as the lymphatic tissue hypertrophies. Related topics of interest Sinusitis. London: Butterworths. p. In: Mackay IS. Swift AC. 1998:868–883. Jones AS (ed). 4. The complications of sinusitis. 285. Nose and Throat. Bull TR (eds). London: Arnold. p. 6th edn. 1997. The complications of sinusitis. Scott-Brown’s Otolaryngology.

2. 3. Common chemical sensation (irritation and textural quality) is served by free nerve endings from branches of the trigeminal nerve in the oral cavity and nose with a contribution from the glossopharyngeal and vagus nerves in the oropharynx. with subsequent cell depolarization and a neural action potential. These fibres are stimulated by (unpleasant) mechanical. Gustation (taste) is served by the taste buds. Physiology 1. although there are regional differences in their concentration and distribution. Information is ultimately passed to the cortex via the thalamus. Odorant molecules (those molecule with the ability to bind and stimulate olfactory receptors) are carried into the nasal cavity with (inspiratory and expiratory) airflow. however. that different odorants have different rates and degrees of solubility in the overlying mucus. Not all olfactory receptors respond equally or at all to different odorants. with their primary afferents synapsing in the tractus solitarius in the medulla. . resulting in the production of an intracellular secondary messenger (usually cyclic AMP). Olfaction (smell) is provided by a small area of olfactory epithelium in the vault of the nasal cavity. before sensation passes on to the thalamus and cortex. The olfactory neurones pass through the cribriform plate and sensory information passes to the olfactory bulb and then on to the thalamus. Quite how this sensory information codes for smell is unknown. Gustation. Several different cranial nerves are involved. thermal or chemical stimuli. It is likely that all these factors have a bearing on smell recognition. Degradative enzyme systems appear to exist for stimulant breakdown after neural interaction. 3. 2. Neural stimulation occurs after dissolving of the tastant in a similar fashion to olfaction although the neural pathways are more complex. neither are they equally distributed in the nasal cavity. It is known. which are modified epithelial cells found throughout the oral cavity. sweet and S on the anterior tongue and sour on the lateral border.SMELL AND TASTE DISORDERS There are three chemosensory portions to smell and taste: 1. hypothalamus and cortex. Olfaction. Recent research has postulated that there are certain ‘groups’ of smells that might be recognized by a relatively common mechanism. Common chemical sensation. Bitter tastes are better perceived on the posterior tongue. They may then dissolve in and diffuse through the overlying mucus or they may combine with specific odorant-binding proteins and be transported through the overlying mucus layer. The free molecules or odorant/protein complexes then attach to receptor proteins.

5. Probably due to damage of the peripheral olfactory receptors following infection with a neuropathic virus. cloves. Further general investigations will be dictated by the clinical features. A multitude of other causes exist. Some objective measure of olfaction is helpful. usually unpleasant (parosmia). neurological conditions. A full nasal examination including endoscopy will be required to establish any sinonasal disease. sensory and neural. metabolic and connective tissue disorders. The majority of patients (60–75%) with sinonasal disease describe anosmia rather than hyposmia. Investigations A thorough history must be taken and any temporal relation to an upper respiratory infection or head injury noted. (Sensory). Management Sinonasal disease should be managed as appropriate to the condition. Commercial ‘scratch and sniff’ kits are available using a forced choice technique which greatly increase their sensitivity. 2. etc. Clinical features The patient may complain of loss (anosmia). toxin exposure. Radiological imaging (including CT scans) of the sinuses may be required. A small proportion in both groups (10–20%) will improve with the passage of time. lemon or coffee. Little is known about the idiopathic group and certainly no treatments .g. Hyposmia is a more common symptom following URTI. they can be useful for deciding if a patient is suffering from anosmia or is malingering. The sense of smell can be crudely tested using a variety of recognizable odours. including systemic disease. although in some cases the local inflammatory response may alter the overlying mucus or the function of the receptor cells. previous nasal surgery. It is important that the test scents are not too pungent or irritant (e.SMELL AND TASTE DISORDERS 295 Pathology It is uncommon for common chemical sensation or taste to be lost. Others (15–20%). drug therapy. diminution (hyposmia) or alteration. (Transport). In this last case the patient is often confusing taste with flavour as taste is rarely lost. (Neural). Head injury (20%). 4. mucosal swelling in rhinitis. Sinonasal disease (20–30%). It has the best prognosis in terms of response to treatment. Idiopathic (20%). The main causes of disorders of smell and taste are as follows: 1. Management of any systemic causes is as for that condition and drug-induced problems may require a change of medication. For example. Serious head injury can result in shearing of the olfactory filaments as they pass through the cribriform plate or direct contusion of the olfactory bulb or cortex. In most cases this is due to simple mechanical obstruction (polyps. It is more likely that olfaction may be lost or impaired.) preventing odorants from reaching the olfactory epithelium in the narrow nasal vault.g. e. peppermint. there is much redundancy in the neural supply and the sensory distribution is relatively wide. Most losses of taste that patients complain of are in fact loss of olfaction. bleach) as they may then be recognized by common chemical sensation. Following upper respiratory tract infection (15–20%). in the sense of smell or taste. as do those following head injury. Reassurance regarding the absence of serious pathology should be stressed to the post-URTI and head injury groups. 3. Olfactory disturbances tend to be more common with increasing age and fall into three main groups: impaired transport. radiotherapy and old age.

Halitosis. Related topics of interest Allergic rhinitis. Follow-up and aftercare This should be as appropriate for the underlying cause. but some surgeons will see if the patient has any response after a trial of using a steroid nasal spray. 115. Nasal polyps. Getchell TV. p. 1991. 11. New York: Raven Press. Smell and Taste in Health and Disease.296 OTOLARYNGOLOGY are available. . Medical Clinics of North America. p. 174. p. Disorders in taste and smell. p. 1991. Bartoshuk LM and Snow JB (eds). Doty RL. 75:1321–1348. Leopold DA. Some authorities claim that a trial of zinc supplements should be administered. Further reading Mott AE. 131. Intrinsic rhinitis.

As a consequence patients with severe OSA are at risk from increased mortality due to cardiovascular disease. This obstruction has three effects: 1. the Venturi effect and the decreased muscle tone associated with sleep can all predispose to upper airway collapse. which may cause cardiac dysrhythmias and if severe and prolonged may lead to pulmonary and systemic hypertension and cor pulmonale. Pathophysiology The noise of snoring is produced by vibration of the soft palate and pharyngeal walls caused by turbulent airflow and the Bernouli effect from a partial obstruction. Sleep apnoea can be obstructive. In obstructive sleep apnoea (OSA) there is complete upper airway obstruction yet the patient continues to make respiratory efforts to overcome this. 2. Any cause of airway narrowing from nares to glottis can contribute to increased airway resistance. Sleep apnoea is classified as mild (AI=5–20).Pringle Definitions • • • • Snoring: a noise generated as a result of partial upper airway obstruction during sleep. Apnoea index (AI): the number of periods of apnoea per hour. . Neuromuscular incoordination interfering with the reflex activity of the pharyngeal dilators associated with inspiration. Central apnoea is due to a defect of autonomic control of respiration in the medulla or peripheral chemoreceptors resulting in a failure of respiratory drive. It is a symptom of serious neurological disease and is not considered further here. Sleep apnoea syndrome can be diagnosed if there are more than 30 apnoeic episodes in 7 h of sleep or if the apnoea index is more than 5. which is an attempt to overcome the obstruction and if frequent results in poor sleep quality. and consequently airflow. moderate AI=20–40) or severe (AI > 40). arousal. increased negative intrathoracic pressure and increased cardiovascular strain. increased compliance of pharyngeal tissues. ceases for a period of time.SNORING AND OBSTRUCTIVE SLEEP APNOEA M. respiratory effort. Hypopnoea: 50% or greater reduction in normal tidal volume. central or mixed. hypoxia. Apnoea:a period of no airflow at the nose or mouth for at least 10s. In central apnoea. The obstruction occurs when the negative intraluminal pharyngeal pressure exceeds the ability of the dilators to hold the pharynx open. 3.

A thorough history and examination is needed. electrocardiogram (ECG). while taking the history it is preferable to have the bed partner present. The manoeuvre is then repeated with the endoscope positioned just above the soft palate (velopharyngeal level). Palatal surgery is far less effective in patients with a body mass index of > 30. very obese = > 40. sleep nasendoscopy. 3. This measurement helps define degree of obesity. morning headaches. . It is calculated by dividing the weight in kilograms by the height in metres squared (Kg/m2). 4. ECG. General investigations. a variety of tests have been developed including lateral cephalometry. OSA often leads to excessive daytime somnolence. personality change. In children it most commonly occurs around the age of 5 years when lymphoid hyperplasia is at its greatest. abdominal and chest movements. Investigations 1. endocrine disorders. chest radiograph. airflow. For some patients this reassurance will be enough others will request further treatment. An overnight sleep study. impotence and an increased risk of a road traffic accident. in the obese and in those with a high alcohol intake. overweight=26–30. Accurate assessment is essential to guide treatment. Probably the most widely used test is the Muller manoeuvre. intellectual deterioration. Body mass index (BMI). Snoring occurs in 10% of men under 30 years of age and 60% of men over 60 years of age. electromyogram (EMG) (to detect periodic limb movements). while OSA can be found in approximately 6% of men. To differentiate between palatal and tongue base or multi-segmental obstruction. It does not detect arousal’s (which are triggered by high negative intrathoracic pressure rather than hypoxia) and may miss ‘high upper airways resistance syndrome’ (HUARS). Normal BMI=19–25. This is probably because these patients are more likely to have OSA with multisegmental or tongue base level collapse. Site of obstruction. To identify sleep apnoea. cine CT and somnofluroscopy. One technique involves overnight video recording. This involves positioning per nasally a flexible fibreoptic endoscope to the level of the tongue base with the patient in the sitting position and with the mouth closed. Polysomnography is the gold standard and involves recording an electroencephalogram (EEG). It is important to establish whether the patient has simple snoring or OSA. The patient inhales vigorously while the nares and mouth are occluded and the degree of hypopharyngeal collapse noted. hence there will never be one single universal cure for snoring. to exclude any exacerbating factors (drugs. This is expensive in terms of time and equipment but is an ideal research tool.298 OTOLARYNGOLOGY Clinical features Snoring and OSA in adults is more common with increasing age. These consider full blood count (FBC). In this way the level of obstruction can be identified in up to 85% or cases. The latter two are research tools. manometry. in men. oxygen saturation. obese=30–40. • General Patients with simple snoring and mild OSA can be reassured that there is no evidence of long term health risk. Effective screening sleep studies may be performed excluding EEG and EMG. 2. Snoring can be immensely socially disruptive and may lead to marital difficulties. Treatment Snoring and OSA are often multifactorial conditions with a variety of primary causative factors. Overnight pulse oximetry will detect all those with severe OSA but may miss some with moderate OSA. body position monitor and microphone recording of the snoring. thyroid function tests (TFT). anatomical) and to identify the site and level of obstruction.

LAUP is sometimes performed under a local anaesthetic. Uvulopalatopharyngoplasty (UPPP) involves tonsillectomy and excision of the uvula. This appliance is worn in the mouth overnight It is like an upper and lower gum shield attached in such a way as to hold the lower jaw forward. Medical treatment of rhinitis. The air acts as a pneumatic splint holding the upper airway open and preventing snoring and obstructive episodes. it can significantly improve a patients quality of life. OSA is in most cases adequately dealt with by adenotonsillectomy as this is the usual site of obstruction. Mandibular Positioning Devices. In retrognathia mandibular osteotomies may be required. iii. If nasal CPAP or pharyngeal surgery are contemplated any nasal obstruction should be corrected first. Nasal Continuous Positive Airways Pressue (nasal CPAP) is the gold standard treatment. Somnoplasty. ii. Long term effects on the temporomandibular joints are not known. Early results are encouraging but there are no long term studies. the use of the “Nozovent” nasal splint or Breathe Right nasal strips to open the nasal valve or surgical correction of a septal deviation. i. With a history of OSA sedative pre-med should be avoided. A new technique in which low temperature radio-frequency energy is delivered via a needle placed into the soft palate. This may be related to later weight gain.SNORING AND OBSTRUCTIVE SLEEP 299 Weight loss is very important and advice with regard to alcohol and sedative medication are often helpful especially in patients with OSA. It is recommended for certain individuals with simple snoring. iv. In severe OSA. Adenotonsillectomy. LAUP (laser assisted uvulopalatoplasty) is a technique in which the uvula is vapourised by the laser and troughs created through the soft palate to each side of the uvula base to form a neouvula. a tracheostomy can be lifesaving. In patients with morbid obesity and life threatening obstructive sleep apnoea bi-maxillary and bimandibular advancement osteotomies have been performed together with significant success rates reported. It can be extremely effective but compliance is often a problem. Hyoid suspension techniques to advance the hyoid and hence move the tongue base forward have been tried with some success. though this can not be guaranteed. In appropriately selected patients all these procedures have a 70–80% success rate. This results in an area of scarring and hence stiffening of the soft palate. Despite the procedure. This surgery can be very painful and complications include nasopharyngeal reflux and dry mouth. This in turn draws the tongue base forward enlarging the pharyngeal airway. • In moderate to severe OSA due to tongue base and multisegmental airway collapse surgery is not particularly effective and anaesthetic risk is significant. i. • Nasal obstruction. turbinate hypertrophy or nasal polyps may all help snoring by overcoming nasal obstruction. . • Maxillofacial. In children. • Oropharyngeal obstruction causing simple snoring and OSA. ii. Laser palatoplasty involves excision of the uvula and scarring of the soft palate with the laser in a variety of ways to induce palatal stiffness. when all other forms of treatment have failed. Air under pressure is delivered via a tight fitting nasal mask. • Tracheostomy. though long term rates are around 50%.

Scott Browns Otolaryngology.B. p. Tonsillectomy.. Related topics of interest Adenoids.B. 8. 6th edn. p. p. . Tracheostomy. 333. Pringle M. 1997. pp. 1–22. Snoring and sleep apnoea. 336.300 OTOLARYNGOLOGY Further reading Croft C.

Instruments. Speech material. in general. In the human. A great number of lists of appropriate speech material have been developed by various agencies e. Phonemes are the building blocks of speech and represent the smallest unit of recognizable speech sound (e. and Bench. Standardized. as opposed to the free-field situation with loudspeakers. allows each ear to be tested individually and allows the non-test ear to be masked.g.SPEECH AUDIOMETRY In many animals the sense of hearing is adapted for a specific purpose. masking of the non-test ear is required on all occasions. Institute of Hearing Research.g. prepared speech material presented by cassette and controlled by the audiometer is much more preferable. It is useful in a variety of contexts including: • • • • Assessment and diagnosis of peripheral and central hearing disorders. the ear is specifically tuned to the speech frequencies (500–4000 Hz). Indeed.and postoperative assessment). As speech audiometry is a suprathreshold test. ay. Procedure The subject is seated in a soundproof room and instructed in the test procedure. Evaluation of the benefit which might be obtained by an operation (pre. Speech material presented by the tester using a microphone is prone to variation in both intensity and accent. Testing is performed in a soundproof room using a cassette player or microphone with the volume controlled from the audiometer which presents speech material to the subject via loudspeakers or headphones. speech audiometry implies the formal qualitative assessment of a subject’s perception of speech.There are 49 phonemes in the English language. Koval and Bamford (BKB) sentences (University of Manchester). Speech audiometry provides a measure of this ability and any corresponding deficit. ah. 2. Voice tests can be considered as a very basic form of speech audiometry. Fry. Medical Research Council. etc. It measures the actual disability produced by the hearing impairment. most of the handicap of hearing loss is due to loss of the ability to perceive the spoken word.). The main function of the human ear is therefore the perception of speech. aw. Speech material is chosen to provide a representative balance of phonemes and can be presented as words. Materials 1. The recorded word lists are presented to the patient monaurally over headphones at various sound intensities. Masking sounds in speech . Boothroyd and Manchester junior word lists. Medicolegal assessment. sentences or synthetic sentences which have no meaning. The use of headphones. However. Prediction of the usefulness of a hearing aid.

Subsequent presentations are usually made at +10. no matter how loud the volume is turned up. The subject is asked to read text aloud. This is the dB level at which the patient achieves half the ODS in comparison with the level at which normal individuals achieve 50%. The gradient of the middle portion of the curve is often less and a plateau may be reached in which further increases in sound intensity do not improve discrimination.302 OTOLARYNGOLOGY audiometry are chosen to try and recreate an appropriate noise background such as speech. It is a measure of optimal performance and should be 100% when normal. (c) The half-peak level (HPL) refers to the sound level (dB) at which the discrimination percentage is half the ODS. . In patients with a sensorineural hearing loss there is usually a loss of ability to discriminate speech. Speech audiometry can be used in the investigation of non-organic or feigned hearing loss. (d) The half-peak level elevation (HPLE) refers to the difference between the pathological and normal HPL. -10 and -20 dB from this level. Shape of the graph If the hearing is normal all the words will be understood if they are played loudly enough. This is considered to be the most valuable diagnostic score. cocktail party and babble noise. +20. Pink noise (equal energy for each octave over the hearing range) is often used when these are unavailable. Non-organic hearing loss. The recorded data can then be used to formulate certain scores and the shape of the graph used to give information regarding the type of deafness. The speech is relayed to the test ear with a delay of 1–200 ms. The result is a sigmoid-shaped curve with a steep. and consequently the ODS is often less than 100%. In patients with a conductive hearing loss all the words will be understood. using the same tapes and test environment. The patient is asked to repeat the words as accurately as possible and the percentage of words or phonemes which are correctly repeated at each sound intensity (dB) is calculated and plotted on a graph. Scoring (a) The optimum discrimination score (ODS) is the subject’s maximum score. This type of curve is typical of a retrocochlear lesion.e. stammering and a raised voice are almost inevitable. (b) The speech reception threshold (SRT) is the sound intensity (dB) at which the subject can correctly repeat 50% of the presented words. In severe cases ‘roll over’ may occur: beyond a certain point any further increase in sound intensity causes a reduction in the discrimination score. but they must be played louder than for a normal subject. Two tests exist: (a) Delayed speech feedback (DSF). greater HPL) in proportion to the degree of hearing loss. 1000 and 2000 Hz. The first presentation is usually at 20–30 dB greater than the pure-tone average for the frequencies 500. The ODS is still 100% as discrimination is preserved. If there is normal hearing in the test ear. which will have been obtained by testing otologically normal individuals on that machine. although more may be required. The curve is parallel to the normal but is shifted to the right (i. near-vertical portion in the middle. Specific uses 1. The graphical display is compared with the calibration graph for that particular machine.

If the hearing is normal. 24(2): 371–379. 1. 1990. Central auditory function. stuttering is likely when the competing material is 40 dB louder than the test material. For further details on this. Pensak ML. Further reading Ballantyne D. Non-organic hearing loss. . 194. 254. p. p. Pure tone audiogram. London: Butterworth-Heinemann. 2. Handbook of Audiological Techniques. p. the reader is referred to Keith and Pensak (1991). Speech audiometry can also be used as a test of central auditory function. Keith RW. Otolaryngologic Clinics of North America. The patient is asked to repeat speech material delivered to the good ear while competing speech material is introduced to the test ear.SPEECH AUDIOMETRY 303 (b) Competition tests. including speech messages in competing noise. competing messages and overlapping messages in each ear. Central function. Clinical assessment of hearing. interrupted and filtered speech. Related topics of interest Acoustic neuroma. 1991. 45. p. accelerated. This can be done using a variety of techniques.

Young The speech therapist is a member of the multidisciplinary rehabilitation team. motivation and communication needs can have a significant bearing on the prognosis for rehabilitation of communication. following laryngectomy. • surgical voice restoration (SVR) with a voice prosthesis. Hard fibrotic post radiotherapy/ surgery neck tissue will prevent transmission of sound into the oral cavity. assessment and therapy for patients who have dysphagia following head and neck surgery. the rehabilitation of voice. Factors such as speech rate. posture. e. developing compensatory articulation strategies with patients who have had oral surgery. 3. volume. There are three options for alternative voice: • electrolarynx.g. articulation. education and support pre-operatively. An oral examination and communication profile are carried out. oro-mandibular function and are able to swallow. reduce speech rate. Efficient use of the electrolarynx is mainly dependent on neck status. The main aims of rehabilitation are to ensure that patients have optimal communication skills. Electrolarynx The electrolarynx is useful as a temporary measure before oesophageal voice is functionally adequate or before placement of a voice prosthesis. or when it is the patient’s preference. Training is needed to develop accurate placement of the device.SPEECH THERAPY IN HEAD AND NECK SURGERY P. . in cases of radical surgery where prosthesis placement is contraindicated. improve articulatory precision and to establish appropriate phrasing. stomach pull-up. 2. Voice rehabilitation following laryngectomy Ideally laryngectomy patients (and their relatives) should be seen by the speech therapist for assessment. The role of the speech therapist working with patients under-going head and neck surgery is essentially threefold: 1. • oesophageal voice. tension levels. It can be a long-term option when the pharyngo-oesophageal (PE) segment is not viable. hearing.

pitch (where instrumentation is available). e. This test can also be carried out before commencing oesophageal voice training as it provides information about the tonicity of the PE segment. The segment is composed of the inferior constrictor including cricopharyngeus and the upper oesophagus. the speech therapist or ENT surgeon carries out an air insufflation test (Taub and Bugner. articulation. i. to what extent are they able to use their voice with confidence in all situations. setting the PE segment into vibration. etc. Blom-Singer and Bivona. The amount of air pressure needed to produce a voice and the fluency and durability of the voice achieved are noted. dynamic range (volume). 1973). and certain adept patients can be trained to change their own valves. depression and strain on relationships caused by a lengthy period of postoperative aphonia can now be avoided. i. the number of syllables produced per breath on air charge. rate. such that when the stoma is occluded pulmonary air is transmitted through the catheter to below the PE segment. In SVR. which is glued to the stoma. consistency and volume which can be achieved with a voice prosthesis using pulmonary air. can now be changed by a speech therapist/specialist nurse via the stoma. Evaluation of the voice is carried out at regular intervals. Provox and Blom-Singer Groningen button. and much more commonly the in-dwelling type. fluency. e. who also rates tension levels. When secondary placement is planned.SPEECH THERAPY IN HEAD AND NECK SURGERY 305 Oesophageal voice Both oesophageal voice and SVR require a viable PE segment or neoglottis.e. i. This means that much of the frustration. The patient has to learn to dissociate respiration from phonation. maximum phonation time: how long the patient can sustain a vowel on one breath. The air is then released. achieving accurate occlusion of the stoma. Voice prostheses are of two main types: the non indwelling type. availability of the voice. The acquisition of a functional oesophageal voice can take months of intensive speech therapy. There must be adequate apposition of the oesophageal mucosa to form a functional PE segment. The oesophageal speaker has to gain voluntary control of the PE segment in order to take air into the upper oesophagus. .e. Surgical voice restoration Oesophageal voice lacks the duration. producing sound as it passes through the PE segment. After valve placement speech therapy involves: training in maintaining the valve. Many centres now favour primary placement of the prosthesis during laryngectomy so that patients can leave the hospital with a voice. Intelligibility and communication skills can be rated subjectively by naive listeners or by the speech therapist. Indwelling valves. expired pulmonary air passes through the one-way silicone valve in the tracheo-oesophageal wall.g. fluency. including objective measurement of: • • • • • duration. e. when the stoma is occluded. A catheter is inserted via the nose to the level of the stoma and is connected to a housing. breath/voice co-ordination. The patient is asked to speak.e. Ultimately the success of voice rehabilitation is a measure of patients’ satisfaction with their communication. and modifying the speech rate and phrasing to maximise intelligibility.g.g. It is then amplified by the resonating spaces and modified by the articulators in the normal way. There can be difficulties at any stage in this process. Provox II. The tonicity of the segment determines the quality of the voice achieved and the effort necessary to produce it. ease of initiation. voice quality.

the use of a uvula sound as a substitute for / k. Most speech therapy departments organise a club for their head and neck patients aimed at providing information. but individual ENT departments have to decide which is to be their method of choice and ensure that the other alternatives are available to patients if the first option is either contraindicated or unsuccessful.g. e. strength. The available alternatives are not mutually exclusive. Surgical dysphagia The speech therapist should see any patient pre-operatively when post-operative dysphagia is anticipated. Follow-up and aftercare Follow-up as an out-patient or on a domiciliary basis should be available for as long as is necessary for this patient group. Compensatory articulatory strategies following oral surgery All patients should be seen pre-operatively so that the therapist can obtain a sample (preferably taped) of the patient’s speech. lips and palate. oral transit time. laryngeal elevation. The speech therapist then works on improving excursion and control of available articulators and systematic exploration of potential compensatory articulations which will improve the patient’s ability to make phonemic contrasts and hence improve intelligibility.g/ phonemes in a glossectomy patient.g. Fees (fibreoptic endoscopic evaluation of swallowing) is useful to assess the anatomy. the speech therapist continues to rehabilitate the swallow with the gradual re-introduction of oral intake when safe. speed and accuracy of movement of lips. but these are not without complications and the patient remains dependent on the hospital for maintenance of the voice. why and how much. When healing is complete a bedside assessment of the swallow is carried out to identify the risk of aspiration. gastrostomy. tongue and palate. e. When alternative feeding methods are necessary to maintain nutrition. during and after the swallow). This includes: • evaluation of the range. swallow initiation/delay. • the effect of modified textures. clinical signs of penetration (substance entry into the airway above the vocal cords) and aspiration (before. . These compensations are then practised for integration into spontaneous speech.306 OTOLARYNGOLOGY There is no doubt that the best possible voice results are obtained with a voice prosthesis. when. symmetry and clearance of the pharynx at rest and post swallow. Post-operatively. Access to videofluoroscopy or modified barium swallow is essential with this patient group. • assessment of sensation in tongue. It confirms whether aspiration is occurring. The speech therapist can observe the impact of compensation techniques and therapeutic manoeuvres and make recommendations accordingly. postures and manoeuvres on the efficiency and safety of the swallow. It permits full evaluation of oropharyngeal anatomy and impaired swallow physiology. patients are assessed using phonetically balanced word lists to establish an objective measure of their intelligibility across all the phonemes of English. once healing is complete. support and social activities on a long-term basis. • sample swallows observing oral manipulation. Members of the club also carry out pre and post-operative visits to new patients.

Schartz K. 197. 1988. Laryngeal carcinoma. San Diego: College Hill Press. 125:748–756. Laryngectomy. to assist patients to compensate and adjust to their new set of circumstances. 2:216–219. 1993. 143. Laryngectomy. p. . Langmore SE. 203. Fibreoptic endoscopic examination of swallowing safety. p. The Evaluation and Treatment of Swallowing Disorders. p. Air bypass voice prosthesis for vocal rehabilitation of laryngectomees. London: Butterworths. American Journal of Surgery. 124. Dysphagia—Diagnosis and Management. Logeman J. A new procedure. Oral cavity carcinoma. p. where preoperative functional levels are not achievable. 138. 1984. and it is important not to underestimate the trauma suffered by patients who have problems with either of these functions. Olsen N. 1983. Related topics of interest Hypopharyngeal carcinoma. p. Bugner LH. The aim of speech therapy is to achieve maximum rehabilitation and. Logeman J. Taub S.SPEECH THERAPY IN HEAD AND NECK SURGERY 307 Eating and talking are not only essential but pleasurable activities. Manual for the Videofluoroscopic Study of Swallowing. In: Edels Y (ed). Further reading Groher ME. Austin TX: Pro-Ed. Dysphagia. Oropharyngeal carcinoma. 1973.

SPEECH THERAPY IN NON-MALIGNANT VOICE DISORDERS P. False cord phonation (dysphonia plicae ventricularis). Untreated. ENT consultants would diagnose organic problems descriptively (e. Psychogenic aphonia. Conditions that respond well to voice therapy • • • • • • • • Muscle tension dysphonias (e. The latter group of voice disorders are characterised by habitual misuse of the voluntary muscles of the larynx and pharynx and have been classified by Morrison and Rammage (1994) as muscle tension dysphonias. Chronic laryngitis.g. Reinke’s oedema (mild).Young In recent years.g. but also the glottic shape observed on phonation. significant progress has been made towards the understanding of the function and dysfunction of the human voice and applying this new knowledge and technology in the clinical evaluation and treatment of voice pathology. with the exception of transexuals must be referred by an ENT surgeon. typical symptoms (e. pitch breaks. etc). vocal cord bowing). In the light of the above it is important that referral should include not only a description of the structure of the larynx and any organic changes. Globus sensation. these problems can progress to organic changes (e. nodules. Referral to speech and language therapy All patients with a voice disorder. mild dysphonia and discomfort with prolonged talking) can be treated successfully. They describe six typical glottic and supraglottic postures. the patients occupation is important to note as most speech therapy departments will prioritise professional voice users for therapy. Puberphonia.g.g. posterior glottic chink. If these patients are treated early. Previously. visible on laryngoscopy which can be attributed to a particular pattern of underlying muscle misuse. chronic laryngitis. vocal nodules) and other presentations where no structural changes could be observed would be classified as ‘functional dysphonia’. oedema. Early/soft vocal nodules. Together with any relevant ENT findings and previous medical history. Conditions which do not respond well to voice therapy .

glottal attack. resonance. • for collection of data for comparative studies and for research and audit purposes. the patient’s general health. increases compliance and motivation in therapy. which allow the dysphonia to be repeatedly analysed in terms of physical and acoustic parameters. Hard. dynamic range (volume). any previous voice disorders and treatment. Some specialist clinics now have access to instrumentation such as PCLX laryngograph. Objectives for therapy together with an estimated number of sessions required are then set and agreed with the patient. or rigid laryngoscopy with stroboscopy a detailed diagnosis can be made.g. Where sophisticated assessment facilities are not available. the mode frequency. e. Traditional assessment is supplemented with objective analysis of pitch. the onset and course of the dysphonia. Patients can view their larynx on a TV monitor. Sulcus vocalis. traumatic life events. questionnaire for patient’s own evaluation of problem. i. Speech and language therapy assessment commences with an in-depth case history which highlights factors for therapy planning. Reinke’s oedema (severe). quality. phonation: habitual pitch and range. Assessment Joint ENT/speech and language therapy voice clinics are ideal for professional voice users.e. relationship problems. palpatory assessment of laryngeal and pharyngeal tension. . • as a therapy tool to provide instant visual feedback to the patient.SPEECH THERAPY IN NON-MALIGNANT VOICE DISORDERS 309 • • • • • Occult cysts. the therapist’s assessment includes subjective evaluation of: • • • • • • • breathing pattern. Laryngeal papillomata. e.g. and using nasendoscopy. and any predisposing factors. fibrous nodules. the frequency range used and a percentage irregularity measure (a measure of the periodicity of vibration. working conditions. habitual misuse patterns. a profile of how the voice is used. These objective measures can be used: • to provide a baseline before treatment (voice therapy or surgery) and to allow objective evaluation of improvement after treatment. More time is allocated to each appointment.The laryngograph waveform gives quantitative and qualitative information about the closed phase of the vocal cord vibratory cycle. articulation. have a clear understanding of the diagnosis and try some therapy techniques on camera with clear visual feedback. which correlates with perceived hoarseness). This facility helps reduce anxiety.

g. When the healthiest possible voice has been achieved the therapist may refer to a singing teacher. Docherty GJ. perceptual. nasalizing. • a psychotherapeutic approach aimed at releasing anxiety. This is not a simple process as there is limited kinaesthetic and proprioceptive feedback from most of the larynx and vocal tract. The efficacy of speech and language pathology intervention: voice disorders. Journal of Voice. Accurate diagnosis and management of voice problems takes account of laryngological. Occasionally group therapy may be appropriate.310 OTOLARYNGOLOGY Therapy The improved understanding of how phonation is affected by muscle tension imbalance has enabled the development of techniques to elicit specific muscle set responses. 11:297–309. 13:72–104. Language & Hearing Research. culture occupation.g. humming. e. and palpatory case history findings. acoustic. Seminars in Speech Language. Voice therapy with singers involves both speaking and singing voice and generally a programme of therapy helps to achieve an easy natural voice without strain. where patients with similar disorders and a background share common treatment needs. Although there are fundamental principles of therapy for a given disorder. and the patient has to bring previously automatic activity under conscious control in order to change it. general health. Further reading Ramig LO. deep relaxation techniques. programmes of therapy in which specific aspects of voice are worked on separately. Hillman RE. attitude to problem and communication requirements. 1998.g. However therapy is tightly constrained in that techniques must be easy to teach and easy to learn and beneficial effects must be obvious in order to reinforce learning and maintain motivation (Casper. Journal of Speech. 1995). pitch. . The aim is to change behavioural patterns—to disrupt unhealthy motor engrams for voice and speech and establish and habituate healthy patterns. Carding PN. etc. e. or holistic programmes may be employed. Horsley IA. Treatment efficacy: voice disorders. taking into account the patient’s age. use of facilitation techniques e. whose role is to develop technique and advise on singing style. Therapy may include the following approaches: • • • • manipulation of the affected musculature. even if it is not suspected that vocal misuse and abuse was the cause of the problem. therapy has to be tailored to the individual. Organic changes to the vocal cords often lead to maladaptive patterns of voice use which may persist post-operatively and lead to further problems. Verdolini K. 41:101–116. sex. A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia. Voice therapy aims to release the natural voice and/or develop and refine control of specific aspects of voice production to achieve maximum vocal efficiency. yawn-sigh. which create tension leading to phonation problems. resonance. 1990. the Accent method. 1999. intelligence. in which separate features are not directly remedied but improve once a physiologically sound pattern of phonation is achieved. fears. Postoperative voice therapy is advisable in most conditions.

External nasal deformity secondary to craniofacial abnormality. dentigerous and mucous cysts. Acute epiglottitis.STRIDOR AND STERTOR Definitions • Stertor is noisy breathing caused by partial obstruction of the respiratory tract above the larynx. Craniofacial abnormality. especially Treacher Collins syndrome. Congenital (present at birth). nasoalveolar. encephalocele. Lingual thyroid and thyroglossal cyst. Nasal. Micrognathia secondary to a craniofacial abnormality. Parapharyngeal and retropharyngeal abscess. • Stridor is noisy breathing caused by partial obstruction of the respiratory tract at or below the larynx. Dermoid. especially secondary to infectious mononucleosis. • Nose Choanal stenosis or atresia. • Trauma • Inflammatory Septal haematoma and secondary abscess. Infective acute and chronic rhinitis. Acquired. meningoencephalocele. Meningocele. Acute and chronic adenoiditis. Macroglossia. • • Nasopharynx Oropharynx 2. septal and midfacial fracture. Wegener’s granulomatosis. Acute tonsillitis. . Ludwig’s angina. most frequently in those with Down’s syndrome. Stertor Aetiology 1. especially Apert’s syndrome and Crouzon’s disease.

. stenosis. e. angiofibroma. web. tracheomalacia. Complications These are directly related to the airway obstruction and include right ventricular failure and pulmonary hypertension (sleep apnoea).g. Examination of the nose.312 OTOLARYNGOLOGY • Foreign body • Allergy • Neoplasia Allergic rhinitis. vocal cord paralysis. Clinical features Stertor is usually inspiratory but the accompanying features are diverse and depend on the cause. pulse. an intercurrent URTI or if trauma has occurred. In a child it is important to extend the neck to prevent the retropharyngeal soft tissue causing a pseudo-mass. Subglottis Web. stenosis. Malignant. Angioneurotic oedema of the floor of mouth. progression and severity of the stertor and on whether it is causing complications (see Related topics). • Trachea and bronchi: Web. Investigations A lateral soft tissue neck radiograph or an MRI scan may be indicated to show the site of airway obstruction. Treatment Treatment depends on the cause. antrochoanal polyp. symptom progression. cystic hygroma. Stridor Aetiology 1. Benign. haemangioma. aggravating and relieving factors. e. central respiratory arrest (in the first 3 months of life neonates are obligatory nasal breathers). throat (contraindicated in acute epiglottitis) and neck. temperature. • Larynx: Supraglottis Laryngomalacia. compression from vascular and other mediastinal tumours. oropharyngeal and nasopharyngeal squamous cell carcinoma. simple nasal polyps. tracheo and bronchogenic cyst. and acute total airway obstruction. saccular cyst. whether there is sleep apnoea.g. respiratory rate and blood pressure may all be necessary. Glottis Web. A full history should ascertain time of onset. Congenital. nasal T-cell lymphoma.

McGill LC. In the smaller bronchi and bronchioles obstruction accentuates the physiological constriction occurring in expiration to cause an expiratory wheeze. 87% had more than one abnormality including 33% with gastro-oesophageal reflux (see Related topics). Treatment This depends on the diagnosis and the severity of symptoms (see Related topics). expiratory or biphasic. 108:378–383.g. including foreign body aspiration and innominate artery compression chest radiographs are very good at suggesting the correct diagnosis (86% in one study). Immediate treatment or appropriate investigations can thus be instituted. Acute laryngitis.STRIDOR AND STERTOR 313 2. A representative biopsy of a laryngeal or infralaryngeal mass may be indicated. Tracheal and main bronchial airway obstruction causes stridor because of turbulence of air flowing through a narrow but rigid airway that doesn’t collapse. Benign. For certain conditions. Foreign body aspiration in children: value of radiography and complications of bronchoscopy. Utility of radiographs in the evaluation of pediatric upper airway obstruction. Dimler. 1998. or a CT scan of the larynx and lungs may be appropriate. This will usually allow a confident or a working diagnosis to be made. supraglottic stridor is inspiratory. radiographs may be normal.g. A full history combined with examination of the nose. It may be inspiratory. passive opening occurring on expiration. Malignant. Laryngeal. 33(11): 1651–1654. In one study of stridulous neonates. acute laryngotracheobronchitis. the negative inspiratory intralaryngeal pressure indrawing the supraglottic soft tissues. . 1999. Quanounou S. Extrinsic allergic alveolitis. throat and neck is indicated if circumstances permit. laryngeal papillomatosis. diphtheria. Angioneurotic oedema of the larynx or trachea. Donnelly LF. laryngeal or bronchial squamous cell carcinoma. Therefore if the history suggests there may be an aspirated foreign body then bronchoscopy is indicated even with a normal chest radiograph. Walner DL. Annals of Otolaryngology. • • • • • Trauma Inflammatory Foreign body Allergy Neoplasia Thermal and chemical. Rigid endoscopy is still the gold standard of investigation as it allows the most complete examination of the aerodigestive tract. It must be emphasized that in children with a bronchial foreign body. Further reading Zerella JT. Investigations A lateral soft tissue neck and chest radiograph. Clinical features Typically. Journal of Pediatric Surgery. Cotton RT. iatrogenic (intubation and surgical). Acquired. Pippus KJ. e. tracheal. bronchial and external compression from an oesophageal foreign body. e. blunt and sharp external.

p. Nasal malignancy. p. 232. p. p. p. . 203.314 OTOLARYNGOLOGY Related topics of interest Paediatric airway problems. p. 170. p. p. 103. Laryngeal carcinoma. 8. Oropharyngeal carcinoma. 138. Laryngectomy. Nasal granulomas. Adenoids. Foreign bodies. p. 143. 174. 180. Nasopharyngeal neoplasm.

Ear trauma. beta-blocker. Sensorineural • • • • • • • • • • • Idiopathic. acute otitis media or chronic otitis media. from a direct blow. from wax or a foreign body. examination and relevant special investigations. Conductive causes • • • • External ear canal occlusion e. Ototoxic drugs. in particular transverse fractures.g. loop diuretic and chemotherapetic drugs.g. Clinical features In subjects with an identifiable cause of a sudden hearing loss the diagnosis is usually made from a thorough otological and neurological history. in particular aminoglycoside antibiotics. otitis externa. Cerebellopontine angle tumours e. Temporal bone fractures. Central causes e. Viral e. non-steroidal antiinflammatory. Causes of perilymph fistula including round window rupture e. measles and mumps virus. latrogenic. congenital dermoids and meningiomas.g from blast trauma or barotrauma. acoustic or barotrauma (see Related topics of interest).g. Nearly all those with a . acoustic neuromas. Infection e. Menière’s disease (primary endolymphatic hydrops) and secondary endolymphatic hydrops (which may cause Menière’s syndrome). following a brain stem cerebrovascular accident. Usually only one ear is affected and the aetiology often never identified. Autoimmune inner ear disease. latrogenic Serous and purulent labyrinthitis.SUDDEN HEARING LOSS Sudden hearing loss is a significant subjective decline in the hearing acuity occurring either instantaneously or progressively over minutes or hours. It can be classified into conductive and sensorineural causes. cholesterol granulomas.g.g.

heparin). (c) To provide rehabilitation in the form of (i) counselling from a hearing therapist. 167. Ototoxicity. and do not require such urgent rehabilitation. Management All patients with a sudden bilateral sensorineural hearing loss should be admitted to hospital for several reasons: (a) Close monitoring of the hearing by pure tone and speech audiometry is possible and desirable in order to determine whether the hearing is stable. Those with a sudden unilateral hearing loss will have less of a disability and handicap. Sudden hearing loss: eight years experience and suggested prognostic table. Unilateral sensorineural hearing loss: an analysis of 200 consecutive cases. Related topics of interest Otological aspects of head injury. 5. 244. 134.M. p. Perilymph fistula. p. The Laryngoscope. 1983.g. betahistine).g. anticoagulants (e. Kumar A. Management of sudden deafness. 91:3–8. Further reading Byl F. and antibiotics is empirical. Fisch U. telephone receiver and door bell).g. The Laryngoscope. Maudelonde C. Treatment of the idiopathic group with vasodilators (e. Otolaryngology Head and Neck Surgery. Maffee M. steroids. (b) To allow rapid performance of relevant special investigations which may include electric response audiometry. six weeks apart) and syphilis serology in an effort to make a diagnosis. Acoustic neuroma. Labyrinthitis. viral titres (two sets.316 OTOLARYNGOLOGY sudden conductive hearing loss will have a definitive diagnosis made but 60% of the sensorineural group will eventually be labelled as idiopathic of which 60% will recover spontaneously. 38. 218.g. Acute otitis media. antioxidants combined with steroids. p. p. It is generally agreed by those who advocate such treatment that it should commence as early as possible after the onset of the hearing loss and certainly within the first few days of symptoms. Menière’s Disease. . Otolaryngology and Head and Neck Surgery. 1984. 96:14–18. (ii) hearing aid and accessory aid provision (for example amplification of the TV. 1. telephone bell. This will provide a hearing prognosis and enable the patient’s disability and handicap to be assessed. blood viscosity lowering substances (e. 118:737–738. Fitzgerald DC & Marks AS. 1998. MRI in sudden sensorineural hearing loss. 228. dextran 40). p. trauma. Most treatments report a response rate of 60%. purulent labyrinthitis) dictates and they can be investigated as an out-patient. 94: 647–661. p. MRI imaging. 1986. about the same as those who spontaneously recover with no treatment. improving or declining. Chronic otitis media. p. p. As a general rule they do not require admission into hospital unless the aetiology (e.

Reidel’s thyroiditis. and recurrent nodular. Patients with hypothyroidism may or may not have a simple goitre. approximately 8% have nodular thyroid disease of which 50% are solitary. or . on which fine needle aspiration cytology can be performed. The majority of patients with multinodular goitre are euthyroid. These cases are probably best dealt with by a multidisciplinary team including a head and neck surgeon. The differential diagnosis of the solitary thyroid nodule (apart from a colloid nodule) includes a follicular adenoma. multinodular. It is important to have as much information as possible on any patient prior to surgery. multinodular. These are thyroid goitre. Acquired hypothyroidism is usually idiopathic or due to surgical ablation of the gland. nodular. The commonest way for cancer to present is as a solitary thyroid nodule. Classification of goitre • Simple (non toxic) • Toxic • Inflammatory • Neoplastic • Rare goitres Diffuse. with an incidence in the UK of between 1–2 per 100 000. amyloid. Rarely it is associated with inherited dyshormonogenesis such as Pendred’s syndrome (which is the association of congenital hypothyroidism with high tone deafness). De Quervain’s. syphilis. Diffuse. clinical oncologist and endocrinologist. Multinodular goitre can be associated with iodine deficiency which is endemic in patients living at high altitude such as the Alps or Himalayas.C. Within this group. thyroid cyst or carcinoma.THYROID DISEASE—BENIGN J. post-treatment of thyrotoxicosis with radio-iodine. The causes of pathological goitres include iodine deficiency. HIV and lithium. 1. Nodular goitre may be solitary or multinodular. hypothyroidism and hyperthyroidism. Benign and malignant. pregnancy and with the contraceptive pill. Simple (non-toxic) goitre. In the United Kingdom. Patients with thyroid goitre are the most important from a surgical standpoint as it is this group that is often referred to ENT surgeons by general practitioners for primary management. TB. These may be both physiological and pathological. and recurrent nodular. it is estimated that up to 15% of the population have a goitre. Although thyroid nodules are common it is important to remember that thyroid cancer is extremely uncommon. This will also assist in delineation of the most prominent nodule. Hashimoto’s. Hypothyroidism may be congenital or acquired. An ultrasound scan will help confirm the diagnosis. Physiological goitres include puberty. The benign nature of the disease may be confirmed in this way. nodular. The former is usually due to congenital absence or atrophy of the thyroid and untreated leads to cretinism.Watkinson Benign thyroid disease can be analysed from three different aspects which are often interrelated.

Graves disease may also be associated with signs of vitiligo. Neoplastic goitre. This is most common in late middle-aged women. these patients usually have cardiac signs (and not eye signs) and are usually treated medically. These immunoglobulins are usually associated with thyroid eye disease which is caused by a specific antibody called exophthalmos producing substance (EPS) which targets retro-orbital tissue to cause oedema of fat and muscle. Once the diagnosis is made. 4. Inflammatory goitre. Graves disease is caused by circulating thyroid stimulating immunoglobulins (IgG) which bind to thyroid stimulating hormone receptors (TSH receptor) to increase thyroid hormone production. but may become hypothyroid as the disease progresses. but may require further treatment with either the same or another modality. . Because of this. They cause lymphocyte infiltration. There is usually both a transient hyperthyroidism and production of auto-antibodies. patients should be treated with thyroxine suppression and have thyroid function tests once a year. This is a flu-like illness. tuberculosis. About 50% of patients will relapse following medical treatment. and ultimately a goitre. 5. Initially patients are hyperthyroid. The gland is usually firm. This can be a benign adenoma or malignant tumour (see Related topic of interest). Recurrent thyrotoxicosis is treated on its merits. Treatment is with thyroid hormone replacement. (c) Riedel’s thyroiditis is rare and associated with a woody hard. These patients are at a high risk of subsequently developing a thyroid lymphoma. pretibial myxoedema and other autoimmune disorders such as pernicious anaemia. normal free T4). In the presence of subclinical hypothyroidism (high TSH > 10 mU/1. Many patients (whatever their treatment) will be hypothyroid post-treatment and will be on long-term thyroxine replacement therapy. if there are convincing symptoms or a past history of radioiodine treatment. Patients with thyrotoxicosis usually either have Graves disease or a solitary toxic nodule. irregular thyroid gland which histologically shows marked fibrosis. and associated with diffuse swelling and tenderness of the gland. Miscellaneous goitres. sometimes tender. In these patients. and the rise in T4 is often associated with atrial fibrillation. Hyperthyroidism is usually treated either medically using tablets (carbimazole or Propylthiouracil) or with radioiodine. Toxic goitre (hyperthyroidism). amyloid. but rubbery. Rarely surgery may be required for an enlarged gland causing obstructive symptoms or when there is a fine needle aspiration cytology result that necessitates surgery. 3. when good shrinkage is achievable. Radioiodine can also be used to treat large multinodular goitres in the elderly and infirm. then treat with T4 (100 µg/day) if antibodies are positive. For example sarcoidosis. These patients are often elderly with co-existent morbidity such as ischaemic heart disease. 2. The starting dose is usually T4 100 µg/day. Some patients who have had a multinodular goitre for a long time can develop thyrotoxicosis (Plummer’s disease). HIV infection.318 OTOLARYNGOLOGY Hashimoto’s thyroiditis. (a) Hashimoto’s thyroiditis. (b) De Quervain’s thyroiditis is secondary to an acute viral infection. This is thought by some to signify a fibrotic reaction to an underlying carcinoma or lymphoma. atrophy and regeneration of the thyroid. an operation with a ‘near total’ or ‘total’ thyroidectomy is an alternative option. Patients who have solitary toxic nodules are usually best dealt with surgically. Antibodies are directed against thyroglobulin and/or microsomal peroxidase. together with those who have significant eye signs or who request surgery.

However. . Thyrotoxicosis. and whole body staging for lymphoma. or stridor (implying tracheal compression). Anatomical imaging with CT or MRI is useful to assess both thyroid lobes. diagnosing multinodular goitres and excluding contralateral disease. sulphonylureas. A drug history is important because some are goitrogens. e. pulmonary metastasis or associated co-morbidity but the best way to assess upper airway obstruction is with a flow loop. The diagnostic strategy for evaluating the thyroid nodule is shown below. These clinically solitary nonfunctional nodules may be an adenoma. Tracheal or oesophageal compression. the mediastinum.THYROID DISEASE—BENIGN 319 Clinical assessment Depending on the cause and duration of the goitre. hyperthyroid or hypothyroid. Treatment The indications for surgery are: • • • • Suspected malignancy. mediastinal extension or lymphadenopathy. ultrasound cannot reliably distinguish between benign and malignant disease. the visceral compartment of the neck. A chest X-ray may show tracheal deviation. all euthyroid patients should have fine needle aspiration cytology performed and a vocal cord check is advised in those with any voice change. More than 90% of lesions identified with scintigraphy will not concentrate the radionuclide and therefore will appear ‘cold’. Fine needle aspiration cytology is safe. the neck for nodes. It is important to confirm that the swelling moves with swallowing and to note its size. patients may be euthyroid. dysphagia (implying oesophageal compression). a serum calcium and calcitonin may be appropriate. It may also be used to evaluate complex cysts and can distinguish and identify purely cystic nodules. cheap and reliable with a diagnostic accuracy of approximately 90% and is therefore the initial investigation of choice for a solitary thyroid nodule. a cyst or a dominant nodule in a non-palpable multinodular goitre and the likelihood of malignancy in a truly solitary ‘cold’ nodule is between 10% and 20%. If a cyst has been excluded on ultrasound. the abdomen. the likelihood of a solid cold nodule being malignant rises to about 50%. Truly functioning nodules (hot) are highly unlikely to be malignant. In addition. Only rarely is a cyst associated with a thyroid cancer. or is ‘cold’ (and therefore not functioning). the chest. Radionuclide scintigraphy using I123 can be used to identify whether a nodule is ‘hot’ (takes up isotope) and therefore is functioning. Investigations All patients with a goitre should have their thyroid function and thyroid antibody status checked.g. The goitre may produce discomfort on swallowing. The latter is suspected from dullness to percussion over the manubrium. Examine the rest of the neck for nodes and perform indirect or fibreoptic laryngoscopy to check the mobility of the vocal cords. position and any retrosternal involvement. carcinoma. Ultrasound may be helpful in measuring tumour size. Cosmetic reasons. difficulty in swallowing and breathing and in those patients undergoing surgery. Depending on the history.

while a total lobectomy completely removes one thyroid lobe with the isthmus. Hemithyroidectomy (total lobectomy). A subtotal thyroidectomy is bilateral removal of more than one half of the thyroid gland on each side plus the isthmus and is rarely performed nowadays. Subtotal thyroidectomy.320 OTOLARYNGOLOGY Types of surgery The following operations can be performed on the thyroid gland: • • • • Lumpectomy. A lumpectomy is removal of the nodule alone with minimal surrounding thyroid tissue. A ‘near total’ thyroidectomy is a total lobectomy and the isthmusectomy with removal of more than 90% of the contralateral lobe and is often done to preserve blood supply to parathyroids on one side. Near-total or total thyroidectomy. A .

This may recover and if so is covered with calcium replacements. If there is still evidence of subclinical hypothyroidism. This is particularly common in the elderly and in those who have positive thyroid antibodies. 2. (c) Hypothyroidism (secondary to extensive removal of thyroid tissue). (a) Recurrent laryngeal nerve damage. (d) Pneumothorax. but permanent damage is treated with replacement therapy using alphacalcidol. surgery for large goitres and can be reduced when operations are performed by an experienced surgeon and by use of a nerve stimulator. (b) Tracheomalacia (uncommon). (b) Thyroid crisis (acute exacerbation of thyrotoxicosis). Injury to related anatomical structures. Complications of thyroidectomy As well as the hazards of any surgical operation there are specific potential local and general complications of thyroidectomy. patients may well require long term thyroxine replacement therapy. Follow-up and aftercare In those patients who have had a hemithyroidectomy. Treatment is with evacuation. (d) Poor scar. (a) Tetany (hypoparathyroidism which is secondary to parathyroid removal or bruising). Patients who have had a ‘near total’ or ‘total’ thyroidectomy usually require immediate Thyroxine replacement therapy . (d) Late recurrence of thyrotoxicosis (incomplete removal of the toxic gland to include the pyramidal lobe) 3. 1. In general.THYROID DISEASE—BENIGN 321 ‘total’ thyroidectomy is removal of both thyroid lobes and the isthmus with preservation of the parathyroids and a completion thyroidectomy is a subsequent procedure to convert a lesser operation into a near total or total thyroidectomy. It can cause tracheal compression. It is related to the experience of the surgeon and increased for operations involving malignancy and for revision surgery. the minimum operation that should be done on the thyroid gland is a total lobectomy. (a) Haemorrhage which can be immediate or delayed. thyroid function is checked at 6 weeks to check the contralateral lobe is functioning normally and if not a further blood test is done at 3 months. (c) Wound infection. The incidence of damage to the recurrent laryngeal nerve is approximately 2%. (c) Damage to the trachea. Hormonal. Complications of the wound site. The incidence is unknown but is increased in surgery for cancer. (b) Damage to the external branch of the superior laryngeal nerve.

Clinical Medicine. 1990. The thyroid axis. . 2nd edn. 798–809. p.322 OTOLARYNGOLOGY and all patients following thyroidectomy should have a vocal cord mobility checked so that the true incidence of cord paresis for one particular surgeon can be documented. Further reading Drury PL. Corrected serum calcium levels should be performed routinely 24 hours post-operatively to counteract iatrogenic hypoparathyroidism. Clarke ML (eds). London: Baillière Tindall. Related topic of interest Thyroid disease—malignant. In: Kumar PJ. 322.

which are usually to the lungs. • Intrathyroidal: greater than 1 cm. Classification There are various types of thyroid tumours and these are shown in Table 1 below. While papillary carcinoma can be identified on . It is less common than papillary thyroid cancer (10% of all thyroid malignancy) and usually presents as a solitary thyroid nodule or occasionally with either distant bony metastases or cervical node involvement (about 10%).C. • Extrathyroidal: extending beyond gland capsule and/or lymph node metastases. Papillary adenocarcinoma. These are: • • • • • • • Natural diet deficient in iodine. Follicular adenocarcinoma. Genetic predisposition. Papillary adenocarcinoma (along with follicular adenocarcinoma) is a differentiated thyroid cancer and accounts for 80% of thyroid malignancy.Watkinson Aetiology Carcinoma of the thyroid gland is not common. Male gender. 2. Follicular adenocarcinoma occurs in older age groups between 40 and 60 years and is seldom seen under the age of 30. on occasion. but is often multicentric. 1. A history of previous ionizing radiation. Papillary thyroid cancer either exists in a pure papillary form. It occurs in all ages and is the commonest type of thyroid cancer in children. Its various types are: • Minimal (or microcarcinoma): less than 1 cm.THYROID DISEASE—MALIGNANT J. be the only initial presenting feature. Chronic lymphocytic thyroiditis. Increased secretion of thyroid stimulating hormone. History of previous thyroid cancer. Less than 10% will have distant metastases. It is associated with a high incidence of cervical lymphadenopathy which may. It usually presents as a solitary thyroid nodule. as mixed papillaryfollicular carcinoma or as the follicular variant papillary carcinoma. Several factors are now known to be important in its causation.

Therefore. 4. Treatment of anaplastic carcinoma with radiotherapy is often ineffective. . it is not possible to diagnose a follicular carcinoma using this technique since it cannot distinguish an adenoma from a carcinoma. Genetic screening is now possible for familial disease using the ret proto-oncogene. Primary thyroid lymphomas are uncommon and account for fewer than 5% of all lymphoma cases. The clinical presentation can be identical to anaplastic carcinoma and both these conditions should be excluded from each other by open biopsy. The autosomal dominant MEN IIa is associated with phaeochromocytomas (10%) and parathyroid hyperplasia (60%). a diagnostic thyroid lobectomy is usually required. They have a bad prognosis. as familial non MEN disease or in sporadic form. 3. Medullary cancers arise from the parafollicular or C cells which secrete calcitonin and this can be a valuable tumour marker. 5. Therefore. Medullary thyroid carcinoma. These tumours are common in elderly women and many are superimposed on a long standing multinodular goitre. In patients with MEN.324 OTOLARYNGOLOGY Table 1. Lymphoma. Its histology comprises of swarms of small cells and can be difficult to distinguish from lymphoma. MEN IIb is medullary carcinoma associated with mucosal neuromas. Once the diagnosis is made. and cervical node metastases are common. are aggressively malignant and rapidly invade surrounding structures. patients require formal staging and treatment is with radiotherapy plus or minus chemotherapy. phaeochromocytomas and Marfan’s syndrome. it is frequently bilateral (90%) and multifocal. They present with rapid thyroid enlargement. and CD4/CD8 lymphoid cell markers is required. Anaplastic carcinoma. Classification of thyroid tumours fine needle aspiration cytology. They usually present as a rapidly increased swelling of the neck in an elderly woman and there is often a history of Hashimoto’s thyroiditis. This condition accounts for about 5% of all cases of thyroid malignancy. immunohistochemical staining for cytokeratin squamous cell marker. which has a good prognosis. It may occur as part of the multiple endocrine neoplasia (MEN) syndrome. a tracheostomy may be required and most patients are dead within one year.

Metastases in ipsilateral node. All categories may be subdivided into (a) solitary tumour. The experience of the surgeon is also important. The extent of surgery is important with survival rates being the best in a group of patients who have total thyroidectomy and radio-iodine ablation. Tumour size is important as is tumour histology with papillary tumours doing better than follicular and both of these do better than medullary. (b) multifocal tumour N0 N1 N1 N1b No regional lymph node metastases. The presence of nodal metastases.THYROID DISEASE—MALIGNANT 325 Investigations All patients should have thyroid function tests and thyroid antibodies. Whole body staging for lymphoma is done with CT. midline. An ultrasound may be useful to measure the size of the primary tumour. Tumour of any size extending beyond the thyroid capsule. Regional lymph node metastases. Extent of surgery. Tumour size. Tumour histology. Treatment with postoperative radio-iodine. Nodal metastases carry a worse prognosis in the elderly and patients do worse in the presence of local or distant spread. Management There are a number of treatment modalities for thyroid malignancy: . Patients over 45 do worse and women do better than men. Staging T1 T2 T3 T4 Tumour < 1 cm. local invasion or distant spread. Metastases in bilateral. Prognostic factors There are a number of prognostic factors associated with differentiated thyroid cancer and these are listed below: • • • • • • • • Age. Thyroid hormone manipulation. Tumour 1 cm-4 cm. Tumour > 4 cm. Patients with advanced disease should be imaged with CT or MRI. to assess the contralateral lobe and to facilitate FNA in certain cases. Many will present with a solitary thyroid nodule so will have had FNAC. or contralateral cervical or mediastinal nodes. Sex.

In these cases it seems entirely reasonable to advocate a conservative approach with hemi-thyroidectomy. a selective neck dissection of levels II to V or VII is carried out as appropriate. . Papillary adenocarcinoma The treatment of this cancer is with surgery and the outlook is excellent. Stage and Histology (GASH) is shown below: • • • • • Gender. Chemotherapy. There is a risk that the tumour will be multicentric. As the tumour size increases. However. the jugular vein is palpated and any suspicious nodes in levels II to V and VII are sent for frozen section and. This allows a surgical treatment strategy as shown in Table 2. if involved. Data from the Mayo clinic shows that patients who have tumours which measure less than 1 cm in size have an excellent prognosis and a 99% chance of living 20 years (the T1 lesion). At the time of surgery. Modified radical or radical neck dissections may be required. All patients with differentiated thyroid cancer require a level VI dissection as part of the total thyroidectomy. Radio-active iodine. Tumour histology. survival rates fall and certainly any patient with a tumour which measures greater than 3 cm or one with local or distant spread should be treated with total thyroidectomy and radio-iodine ablation. Patients can be divided into high risk or low risk (females under 45 are low risk) and there are low risk and high risk tumours (low risk tumours measure less than 1 cm in size). some may prefer to advocate total thyroidectomy and radio-iodine ablation. Follicular adenocarcinoma For follicular carcinoma. thyroid hormone suppression and serial thyroglobulin measurements. External beam radiotherapy. Those tumours greater than 1 cm and those associated with cervical or distant metastases are high risk. Clinically palpable disease requires at least a selective neck dissection involving these levels. distant spread is more common so that tumours less than 1 cm which exhibit minimal invasion can be treated with conservative hemithyroidectomy but the rest (which will be the majority) require total thyroidectomy and radio-iodine ablation. Treatment of the T2 lesion (1–4 cm) remains controversial but again following thyroid lobectomy for a suspicious FNA based on current data. it is reasonable after discussion with the patient to offer a conservative approach for tumours less than 3 cm in size when age and gender indicate a low risk patient. Age. Nodal and distant metastases. Tumour size.326 OTOLARYNGOLOGY • • • • • Surgery. Treatment of differentiated thyroid tumours based on risk stratification A risk stratification based on Gender. Age. Hormonal manipulation.

Medullary thyroid cancer Treatment for this is surgical. Protocols are available and patients are put on suppressive doses of T4 and an I131 whole body diagnostic scan carried out after ablation to confirm whether or not the treatment has been successful. The strap muscles may need to be divided. British Association of Otolaryngologists. In: Stell and Maran’s Head and Neck Surgery. Further reading The management of the solitary thyroid nodule: a review by RM Walsh.THYROID DISEASE—MALIGNANT 327 Table 2. It is usually possible to perform conservative surgery preserving at least the accessory nerve as well as sometimes both the sternomastoid muscle and the internal jugular vein. Second Consensus. The treatment of anaplastic carcinoma and lymphoma has already been discussed. Total thyroidectomy for cancer The following points are important when performing the above operation: • • • • • • • • Adequate access is required via the appropriate incision. Level VI dissection should always be done with a total thyroidectomy. Tumours of the thyroid and parathyroid glands. 24:388–397. 4th Edition. 1999. Vol. Usually level I does not need to be dissected in the untreated neck. Visceral extension into the larynx or pharynx may require extensive surgery. Any uptake in the neck requires a therapy dose of I131. Identify and attempt to preserve both recurrent laryngeal nerves. . Wilson J (ed). A total thyroidectomy is done with a level VI dissection and any palpable nodal disease requires modified radical or radical neck dissection. Any involved nerve should be resected. Major vessel involvement is uncommon but usually indicates inoperability. Parathyroid preservation is important. ButterworthHeinemann. Surgical treatment of differentiated thyroid cancer Following total thyroidectomy. 2000. Effective Head and Neck Cancer Management. JC Watkinson & J Franklyn. Head and Neck Surgeons. radio-iodine ablation of the residual normal thyroid tissue can be performed in the post-operative period after allowing TSH levels to rise. 2000. Access to the mediastinum may be required. In: Clinical Otolaryngology.

Less than 1% of the adult population have tinnitus of sufficient severity to seriously affect their quality of life (although up to 8% may seek medical advice about it). Central processing. Hyperacusis (as distinct from recruitment) is found as an associated symptom in about 40% of tinnitus sufferers. Pathophysiology The cause of tinnitus is not known. (b) This signal will undergo extensive auditory processing before it is perceived as tinnitus. by any mechanism. Recent years have seen an increased appreciation of the role of central signal processing in tinnitus perception. may cause damage to the myelin insulation between axons in the peripheral auditory system. There are several hypotheses which attempt to explain these phenomena: 1. Epidemiology Tinnitus is a common experience with up to one third of the adult population experiencing it at some time in their life. Hyperacusis can be defined as an undue sensitivity and distress to everyday sounds that would not normally trouble a ‘normal-hearing’ individual. This definition excludes vascular sounds and bruits. Hence the association with a high tone hearing loss. 2. 3. Cross talk. A ‘neurophysiological’ model has been developed which suggests three phases in the aetiology of tinnitus: . It has been postulated that damage to the cochlea. In developing an understanding of tinnitus mechanisms two points should be borne in mind: (a) There is a generated potential somewhere in the auditory system. leading to ‘cross-talk’ between them and thus to phase locking of spontaneous neural activity.TINNITUS Definition Tinnitus is the sensation of sound not brought about by simultaneously externally applied mechanoacoustic or electrical signals. experienced subjectively as tinnitus. Altered auditory firing rate. There is some evidence that tinnitus is associated with an increase in the spontaneous firing rate of auditory nerve fibres. The prevalence of tinnitus increases in association with a high frequency hearing loss although the association between severity of tinnitus and degree of hearing loss is very weak.

General causes. It should be remembered that 10% of acoustic neuromas present with markedly asymmetrical tinnitus. and finally. These include cardiovascular disease (hypertension. Associated conditions 1. • Loudness discomfort levels are useful if there is any co-existent hyperacusis. Objective tinnitus may be found in palatal myoclonus. neuropathy) may also lead to tinnitus. These tests make the assumption that the characteristics of an external sound can be meaningfully related to those of an internally generated sound. Almost every ear disease and cause of deafness can be associated with tinnitus. MRI scanning will then be required. 2 . Usually the pitch of the tinnitus is found to be at or around the frequency of the maximal hearing loss and the loudness is usually within 15 dB of the patient’s pure tone threshold at that frequency. Local causes. • Persistence—due to autonomic arousal. Effects on sleep. Audiometric investigations. pulsatile or non-pulsatile). anxiety and negative beliefs. Clinical assessment From the patient’s history confirm that the patient is actually suffering with tinnitus and determine the character of the sound (intermittent or constant. Noise induced hearing loss seems to be particularly frequently associated with tinnitus as does Menières disease.TINNITUS 329 • Emergence of the signal (perhaps due to local cochlea pathology). . When measured sequentially they can indicate response to treatment. Neurological conditions (multiple sclerosis. • Tinnitus pitch and loudness matching may be performed. 2. a hyperdynamic circulation as in anaemia and fever and drugs (particularly salicylates). • Detection and then (usually negative) perception. There is a consensus that psycho-acoustic tests of this kind give no useful information regarding tinnitus severity nor is there any relationship between perceived loudness of tinnitus and complaint behaviour. vascular malformations and exceptionally loud spontaneous otoacoustic emissions. and the great majority of tinnitus sufferers have some measurable hearing loss. • A pure tone audiogram is essential to document any hearing loss. There is also evidence of increased central auditory gain in tinnitus sufferers and it may be this phenomena that explains the frequently associated hyperacusis. Investigations 1 . It is also important to establish how much trouble the patient is having because this will dictate whether and how much treatment is necessary. cardiac failure). It has become clear in recent years that the ‘problem’ of tinnitus relates far more to the individual’s psychological response to the abnormal tinnitus signal than to the signal itself. A full ENT and cardio-vascular examination should be performed to ensure the patient is not hearing transmitted sounds or does not have a potentially remedial causes of tinnitus. Unilateral tinnitus may also be the only symptom of an acoustic neuroma. mood and concentration are found most frequently.

lignocaine. These produce a controllable and more palatable. British Journal of Audiology. 78. These are particularly useful for individuals with a minimal or no hearing loss. ginko biloba amongst others) but success has been limited and adverse effects common. p.330 OTOLARYNGOLOGY 3 . Pure tone audiogram. • Hearing aids. • Many other treatments have been tried (e. D Stephens (ed). Directive counselling involves explaining the problem. Jastreboff PJ and Hazell JWP. In the absence of a clear diagnosis a full haematological screen to exclude anaemia. countering negative beliefs and making efforts to ameliorate the tinnitus sufferer’s reaction to the perception of their tinnitus signal. Useful for those with severe tinnitus and a hearing loss. 2. Objective pulsatile tinnitus may require angiography if a specific vascular lesion is suspected. if tinnitus persists. In: Scott-Brown’s Otolaryngology. London: Chapter 18. 27:7–17. Access to a local self-help group is useful to provide emotional support. • A pillow radio or pillow speaker may help the patient get to sleep. • Combined hearing aid and WNG unit. thyroid dysfunction. 4 . the increased awareness of the background sound tends to make the tinnitus less apparent. Vol. Thereafter. 1993. A neurophysiological approach to tinnitus: clinical implications. 117. Sound therapy or sound enrichment involves the use of background sound. and ideally. melatonin. These are useful for those patients who have a hearing loss. a clinical psychologist. Further reading Coles RRA. Adult Audiology. magnetic and ultrasonic stimulation. p. broad-band sound. hearing therapists. It is thought to act both by reducing the contrast between the tinnitus signal and background noise and improving the plasticity of the central auditory cortex and thereby facilitating a reduction in perception. dyslipidaemias and hypoglycaemia can be helpful. Hearing aids. Related topics of interest Evoked response audiometry. p. Modern treatment is described as habituation based therapy and consists of two main components: directive counselling and sound therapy. hearing aids and/ or white noise generators (WNG) to raise the background ‘sound floor’ and thus reduce the prominence of the tinnitus signal. • White noise generators (WNG). Management Any underlying remedial cause should be treated first. Tinnitus. Butterworth-Heinemann. . lay counselling and relaxation therapy. audiologists. 254. 6th edn.g. If an appropriate aid with maximal gain at around the frequency of the tinnitus is fitted. management is best undertaken by a dedicated team comprising otologist.

Although the disease is seen in adults. and it would be prudent to perform a Paul-Bunnell test. particularly the jugulodigastric nodes. It has been suggested that viruses (e. The tonsil is enclosed by a fibrous capsule. the palatine tonsils and the lingual tonsils (which are embedded in the posterior third of the tongue). In many other cases it is felt that an initial viral tonsillitis may predispose to a superinfection by bacteria ( -haemolytic streptococcus. outside of which is a layer of areolar tissue. The main blood supply of the tonsil is from the tonsillar branch of the facial artery. white cell count and a throat swab. malaise and headache for a day before the onset of the predominant symptom.g. Streptococcus pneumoniae. There may be trismus and dribbling. leukaemia and diphtheria must always be borne in mind. Haemophilus i influenzae and anaerobic organisms). enteroviruses and rhinoviruses) may be responsible for tonsillitis in up to 50% of occasions.TONSIL DISEASES The tonsils are paired secondary lymphatic organs situated on the side of the oropharynx between the palatoglossal (anterior tonsil pillar) and palatopharyngeal folds (posterior tonsil pillar). Swallowing may be painful (odynophagia) and the patient’s voice may sound muffled. which is most often a viral infection involving the lymphoid tissue on the posterior pharyngeal wall and may include the tonsil. Clinical features There may be a prodromal illness with pyrexia. adenoviruses. This separates the capsule from the pharyngobasilar fascia covering the superior constrictor muscle that forms the tonsil bed. it is most frequent in child-hood. In general practice the clinical features usually make the diagnosis obvious without the need to resort to clinical investigations in the majority of cases. There will be tender cervical lymphadenopathy. The ring as a whole is thought to have some protective function as a barrier against infection in the first few years of life. which is a sore throat. The tonsils are found to be hyperaemic on examination with pus and debris in the crypts. There is some doubt regarding the most common causative organisms in acute tonsillitis. how-ever. influenza. a ring of lymphoid tissue consisting of the adenoids. agranulocytosis. Aetiology of acute tonsillitis Although this is a common disease. para-influenza. Cases that are referred to hospital are usually more severe. Pain may radiate to the ears or may occur in the neck due to cervical lymphadenopathy. Some children may have abdominal pain and occasionally vomiting. They are part of Waldeyer’s ring. Glandular fever. . Acute tonsillitis is an infection which primarily affects the palatine tonsil. presumably because immunity to common childhood organisms has not been fully established. It is regarded as being distinctive from acute pharyngitis. its aetiology and pathogenesis are poorly understood.

serological tests and biopsy. Differential diagnosis of ulceration of the tonsil A working diagnosis can usually be determined from the history and clinical examination. Meningitis. • Neoplasia (squamous cell carcinoma or lymphoma). Local. • Acute streptococcal tonsillitis. • Severe swelling causing respiratory obstruction. chest radiograph. it is likely any patient who attends a medical practitioner with the clinical features of tonsillitis will be treated with antibiotics. when a generalized maculopapular rash may develop. Ampicillin should never be used to treat acute tonsillitis in case the patient has infectious mononucleosis. with erythromycin reserved for those patients allergic to penicillin. • Recurrent acute tonsillitis (chronic tonsillitis). Differential diagnosis of unilateral tonsil enlargement • Asymmetry in a patient with recurrent bouts of acute tonsillitis. . Investigations include a full blood count. • • • • Septicaemia. Acute glomerulonephritis. Parapharyngeal. General. Penicillin V is still the drug of choice. • Acute otitis media. • Diphtheria. 2. Complications of acute tonsillitis 1. Aspirin is contraindicated in children because of the risk of Reye’s syndrome. • Abscess formation: Peritonsillar (quinsy). Fluid replacement and bed rest are ancillary measures in the severe attack. Infection. Acute rheumatic fever. Retropharyngeal. • Apparent enlargement (peritonsillar abscess or parapharyngeal mass).332 OTOLARYNGOLOGY Management Even though viruses are implicated as the pathogenic organisms in many cases. • Infectious mononucleosis. Possible causes include: 1. The patient should have paracetamol for analgesia.

Hotaling AJ. • Leukaemia. Silva AB. 1:177–184. • Aphthous ulceration. 3. p. • Salivary gland tumours (adenoid cystic carcinoma or mucoepidermoid tumour). Tonsillectomy. 4. Neck space infection. • Squamous cell carcinoma. p. • Behçet’s syndrome.TONSIL DISEASES 333 • Vincent’s angina. Acute infection of the pharynx and tonsils. • Acquired immunodeficiency syndrome (AIDS). 333. In: Hibbert J (ed). Chapter 4. 1993. • Agranulocytosis. Blood diseases. • Lymphoma. Further reading Hibbert J. Vol. 188. Advances in adenotonsillar disease. Neoplasm. Current Opinion in Otolaryngology and Head and Neck Surgery. London: Butterworths. 5. 1997. 6th edn. Scott-Brown’s Otolaryngology. 2. . 8. p. Other causes. Related topics of interest Adenoids.

Although it is felt that the risk is extremely small. During certain epidemics (e. (Surgeons differ in the definition of this. polio). In some cases the decision to proceed with surgery should be reconsidered in the context of the potential problems. • • • • • Recent episode of tonsillitis or upper respiratory tract infection (within 2 weeks). • Part of another procedure (UVPP. Tonsillectomy and CJD Concerns have been expressed about the potential for contamination of tonsillectomy instruments with ‘prions’ and subsequent development of Creutzfeldt Jakob disease (CJD). Contraindications These contraindications are not absolute.) • Previous episodes of peritonsillar abscess (quinsy). for at least 2 years. but not the mouth gag or Draffins bipods. . Peroperative.TONSILLECTOMY Indications for tonsillectomy • Recurrent episodes of acute tonsillitis. scissors. steps have been taken to minimize it.g. etc) should be disposable. Current advice is that instruments which are in intimate contact with the tonsil (dissecting instruments. Cleft palate. • Gross enlargement causing airway obstruction (sleep apnoea syndrome). access to glossopharyngeal nerve or styloid process). but surgery should be delayed until the particular problem is resolved. Oral contraceptives. Bleeding disorder. Complications of tonsillectomy 1. five per year. • Suspected neoplasm (unilateral enlargement or ulceration). As a rule of thumb these episodes should last 5 days or more.

Haematoma and oedema of the uvula. • • • • • • Secondary haemorrhage. • Anaesthetic complications. repeated swallowing. Late. It is one of the reasons why some surgeons are opposed to day case tonsillectomy. The tonsillar fossae should be inspected to identify a bleeding point. The signs of reactionary haemorrhage are obvious: bleeding from the mouth.TONSILLECTOMY 335 • • • • • Anaesthetic reaction. the patient should be prepared for a second anaesthetic and the bleeding point ligated under general anaesthesia. Infection (may lead to secondary haemorrhage). It is essential to ensure adequate haemostasis at the end of the tonsillectomy procedure as blood in the airway at this time may cause laryngeal spasm or can occlude the airway. The most significant complication is haemorrhage. which occurs in approximately 2% of cases. a rising pulse rate and eventually a falling blood pressure and tachypnoea. Any clot should be removed if possible and a gauze swab soaked in 1:1000 adrenaline applied to the fossa. 2. Secondary haemorrhage occurs some 5–10 days post tonsillectomy and is due to an infection of the fossae. Most of the deaths associated with tonsillectomy are directly or indirectly associated with this complication. 3. A full blood count and . If the bleeding continues. Patients are nursed in the reverse Trendelenburg position (head down) so that blood trickles out of the mouth rather than being swallowed or aspirated. • Reactionary haemorrhage. Blood must be cross-matched and an intravenous infusion started. Haemorrhage. • Tonsillar remnants (which may be the site of recurrent acute infection). Subacute bacterial endocarditis (if the patient has a cardiac defect). Reactionary (primary) haemorrhage by definition occurs up to 24 hours post-operatively. Early. Immediate. Continuing haemorrhage will result in hypovolaemia. and if not corrected circulatory failure (shock) will be the consequence. The second anaesthetic is hazardous and should only be administered by an experienced anaesthetist. If significant. Trauma to the posterior pharyngeal wall (careless insertion of the tongue blade). Damage to teeth. a gurgling sound in the throat on respiration. or there is any doubt. The postnasal space should always be checked for a blood clot (the socalled ‘coroner’s clot'). but the vast majority occur within the first 8 hours. Dislocation of the temperomandibular joint by over-opening the mouth gag. • Scarring of the soft palate (limiting mobility and possibly affecting voice). Pulmonary complications (pneumonia and lung abscess are rare). the patient should be admitted to hospital for observation. vomiting blood. 4. Earache (referred pain or acute otitis media).

336 OTOLARYNGOLOGY cross-match should be performed. penicillin and metronidazole or erythromycin). 330. It is unusual for such a patient to have to go back to theatre and when this is necessary the tonsillar fossae are found to be sloughy and friable and it is difficult to locate and ligate any specific bleeding point. p. Further reading Hibbert J. Snoring and obstructive sleep apnoea. 188. Vol. Acute infection of the pharynx and tonsils. It may be necessary to suture the faucial pillars together. Neck space infections. Current Opinion in Otolaryngology and Head and Neck Surgery. The infection and haemorrhage will usually settle after treatment with antibiotics (i. p. 6th edn. Scott-Brown’s Otolaryngology. Patients who have a tonsillectomy for reasons other than recurrent acute tonsillitis should be followed up appropriately to their problem. or over Kaltostat or a gauze swab which is removed the next day. Advances in adenotonsillar disease. 297. London: Butterworths. uncomplicated tonsillectomy. Patients who have suffered a significant haemorrhage should be reviewed within 2 weeks to check their haemoglobin. Follow-up and aftercare No specific follow-up is required after a routine. p. Tonsillitis. 8. chapter 4. 1993. Silva AB. . p.v. 1:177–184. Related topics of interest Adenoids. Hotaling AJ. 1997. In: Hibbert J (ed). 5.

Advances in anaesthetics. multiple sclerosis). 2. myasthenia gravis. laryngeal web. Trauma (burns of the face and neck. bulbar palsy. Head and neck surgery (oral or oropharyngeal resections. Infection (acute epiglottitis. This will also be discussed in this chapter. Ludwig’s angina). thyroid).TRACHEOSTOMY A tracheotomy is an operation to make an opening in the trachea. those patients undergoing head and neck surgery). • • • • Neurological diseases (polyneuritis. multiple facial fractures). whenever possible. pharynx. gastric contents or blood. Indications for tracheostomy 1. food. Trauma (foreign body. have reduced the number of potential tracheostomies. trachea. This includes patients who need temporary protection of their airway (e. Many disorders are now managed by endotracheal intubation.g. while a tracheostomy means converting this opening to a stoma on the skin surface. bulbar palsy). tetanus. Vocal cord paralysis (thyroidectomy complication. . be carried out as an elective procedure. cerebrovascular accident). • • • • • Congenital (subglottic stenosis. There is an old adage that states ‘the time to do a tracheostomy is when you first think about it’. larynx. supraglottic laryngectomy). head injury. laryngotracheobronchitis. Tracheostomy should. Patients may benefit from a long-term tracheostomy if they suffer from any chronic condition (which are often neurological diseases) leading to inhalation of saliva. but the decision for tracheostomy should not be left until it is too late. laryngeal cysts). or the stagnation of bronchial secretions. swallowing corrosive. Airway obstruction. A cuffed tube will protect the airway from aspiration and allow easy access to the trachea for regular suction. severe head and neck injury. Tumour (tongue. Upper airway obstruction is now the least common indication for tracheostomy. diphtheria. In many centres. percutaneous dilatational tracheostomy has emerged as the principle method for performing tracheostomy in the intensive care unit setting. inhalation of irritants). and this should always be carefully considered first. Children especially can deteriorate very suddenly. Protection of the tracheobronchial tree. less traumatizing types of endotracheal tubes. Coma (drug overdose. including improved.

The patient should be in a well-supported upright position. preventing aspiration and without causing pressure necrosis of the trachea. silicone or other synthetic plastics that are nontoxic. care must be taken in infants that the chin does not occlude the tracheostomy. 3. 2. These patients need monitoring and the administration of carbon dioxide via a flowmeter through the tracheostomy if necessary. These usually consist of an obturator. Humidification of inspired air is essential to prevent drying of the airway. severe asthma. • Pulmonary diseases (chronic bronchitis and emphysema. Most of these are made from PVC. the Portex paediatric tube and the Shiley paediatric or neonatal tube. 2. Metal tubes. A cuffed tube is preferred if the patient needs protection of the lower airway from aspiration or haemorrhage. to prevent a build-up of secretions in the trachea and bronchi. the Portex is not winged but has square-ended flanges. by aseptic technique. Nowadays they have low-pressure cuffs which can remain inflated for days. with loss of stimulation of their respiratory centre. mouth and glottis. Tracheostomy reduces upper respiratory dead space by about 70%. Examples include the silver tubes of Chevalier Jackson and Negus. The Great Ormond Street tube and the Shiley are winged and sit comfortably in the infant’s neck. A sterile catheter is passed well down into each main bronchus in turn. Nursing care. 4. Tracheostomy tubes The selection of tracheostomy tube depends on the reason for the procedure and the postoperative requirements. which encourages the formation of crusts and infection. These are short and should only be used in patients with thin necks. . • Neurological diseases (as above). Tube types can be divided into metal and synthetic. Constant nursing attention is essential for at least the first 24 hours following the tracheostomy. The patient will be unable to cough and clear secretions so suction should be applied regularly. pneumonia).338 OTOLARYNGOLOGY 3. These tubes can be connected to an anaesthetic connector or respirator. but they do not have a cuff. Postoperative management 1. bypasses resistance to airflow in the nose. Synthetic tubes. This is due to lowering of their Pco2. They usually have an expiratory flap valve on the inner tube which allows phonation. an outer tube and an inner tube. Apnoea. thereby allowing the patient to speak. Removable inner tubes facilitate cleaning and removal of crusted secretions while the outer tube maintains the airway. Ventilatory insufficiency. The Alder Hey tube is a typical example of a paediatric metal tube: both the inner and outer tubes are fenestrated and a valve is available to allow transglottic expiration and speech. The Koenig tube has a long flexible wire that can be used if there is a narrowing of the trachea. Some patients with chronic obstructive airways disease may develop apnoea following restoration of their airway. The Durham tube has an adjustable flange so that it can be used in patients with either thin or very fat necks. Examples include the Portex and Shiley tubes. A fenestrated tube permits the passage of air upwards through the glottis. Saline or sodium bicarbonate instillation into the trachea followed by immediate suction also helps to reduce the likelihood of such complications. Humidification. Paediatric synthetic tubes include the Franklin tube of Great Ormond Street. and allows the use of mechanically assisted respiration if necessary (intermittent positive-pressure ventilation). None of the paediatric tubes have a cuff. 1. Suction. • Severe chest injury (flail chest).

A notebook or erasable pad should be provided for the patient to communicate. Patients with a permanent tracheostomy should if possible have a fenestrated tube with a speaking valve incorporated with the inner tube. but some patients may require a nasogastric tube. Immediate. 6. The first tube change is usually done about 48 hours after the tracheostomy and should always be performed by a doctor. • Damage to local structures (cricoid cartilage. recurrent laryngeal nerve. Whenever the nursing staff perform subsequent tube changes it should be done when the whereabouts of a doctor is known in case of a problem. including a period of sleep. The tracheostomy tube may interfere with the normal mobility of the larynx during swallowing. • Primary haemorrhage. • Cardiac arrest. If there is an inner tube it should be taken out and cleaned whenever necessary. • Anaesthetic complications. 7. There may be difficulties in children who have had the tracheostomy for a long period of time. Decannulation. If the larynx is still functioning the patient can be shown how to speak by temporarily blocking the tube while exhaling. oesophagus.TRACHEOSTOMY 339 5. After decannulation the patient should remain in hospital under observation for at least 2 days. and surgical closure by excision of the scar tissue and the tracheocutaneous track may be required in some cases. Replacement or cleaning of the outer tube is usually left for the first 5 days until a track has become established. brachiocephalic vein). A spare tube of identical size and a tracheostomy dilator must always be available at the bedside in case a quick change is necessary. Swallowing. . Some patients may experience problems. • Dislodgement/displacement of the tube. They also have a relatively smaller tracheal airway which may be partly blocked by granulation tissue. Speech. Intermediate. preferably the surgeon who performed the procedure. If a cuffed tube has been used it should be inflated with the minimum amount of air that prevents an air leak. but sometimes because of incoordination and the pressure of the tube’s cuff. Care of the tube. It should only be carried out when it is obvious that it is no longer required. then this should be done weekly or as required. 1. sometimes because of a psychological dependence on the tube. 2. intermediate (1–14 days) or late (>14 days). the outer tube must be held firmly while withdrawing the inner one. Deflation of the cuff will sometimes help. 8. The following list can be a useful basis or plan for an examination answer. • Surgical emphysema. often because of the condition which necessitated the tracheostomy. The tracheostomy tube should be spigoted and removed as soon as is feasible. Complications As with any operative procedure the complications of tracheostomy can be immediate (during the first 24 hours). The patient should be able to manage with the tube spigoted for a full 24-hour period. and it must have a low-pressure cuff to minimize the risk of tracheal stenosis.

Infection (perichondritis. p. Stridor and stertor. Scar (hypertrophic or keloid). Then there is a placement of multiple progressive dilators into the tracheal lumen over a wire that is introduced through this tract. Tracheal necrosis (may lead to tracheal stenosis or tracheo-oesophageal fistula). London: Butterworths. 3. The indications are the same as for conventional tracheostomy. Further reading Bradley PJ. Bronchoscopic guidance is therefore advisable. 5. In reviewing the literature. 1. Scott-Brown’s Otolaryngology. as it increases the safety of the procedure. Bronchoscopic guidance should be used when available. smaller and more aesthetic wound. Related topics of interest Paediatric airway problems.340 OTOLARYNGOLOGY • • • • Pneumothorax. Decannulation difficulty. Indications/contraindications. 7:144–149. 311. enlarged thyroid isthmus. previous tracheostomy. The obstructed airway. chapter 7. Technique. some benefits appear to exist from the procedure. Late. indistinct anatomic landmarks and previous laryngeal or neck surgery. many otolaryngologists remain sceptical about its safety. increased speed. cervical spine fractures. Ciaglia’s method involves a small vertical incision at the lower edge of the cricoid cartilage and blunt dissection is performed to the level of the trachea. evidence of coagulopathy. 2. p. This potentially lethal problem has been reported and associated with deaths. decreased operative bleeding and decreased rate of local wound infection. • • • • Subglottic and tracheal stenosis. The main early problems are from bleeding and paratracheal insertion. Complications. Several techniques are described but the Ciaglia modification of the Seldinger technique has the most support in the literature. Costs also appear to be reduced—and this more than any other medical factor will guarantee its future use. . 232. Paediatric endoscopy. i. Current Opinion in Otolaryngology and Head and Neck Surgery. 6th edn. secondary haemorrhage). New techniques and advances in tracheostomy. Obstruction of the tube or trachea (excessive crusting). p. The question of laryngo. wound infection. Vol. 3.tracheal stenosis as a long-term complication has not yet been adequately evaluated. 237. Percutaneous tracheostomy Percutaneous tracheostomy (PCT) has gained attention as an alternative to the standard tracheostomy technique. 1997.e. Tracheocutaneous fistula. Holtel MJ and Hall DJ. Despite its growing use. The relative contraindications include: age less than 15 years. 1999.

1. There is an ossicular discontinuity. The stapes footplate is fixed and a fenestration of the lateral semicircular canal is performed. The malleus handle is absent. Type 6. The tympanic membrane is reconstructed over the malleus remnant and the long process of the incus. Classification Wullstein in 1953 described five tympanoplasty reconstruction techniques after eradication of middle ear disease. Type 3. Tympanoplasty may be combined with mastoid surgery when there is concomitant mastoid disease in patients with CSOM. 5. This is so called because in birds a single strut of bone. 6. creating a round window baffle.TYMPANOPLASTY Definition Tympanoplasty is an operation to eradicate disease in the middle ear and to reconstruct the hearing mechanism with or without tympanic membrane grafting. . Strictly speaking it is not the same as a type 1 tympanoplasty because eradication of intercurrent middle ear disease is not included in the definition. The incus and malleus have been removed or eroded by disease. Myringoplasty is defined as an operation to repair or reconstruct the tympanic membrane. Only the stapes footplate remains. Type 4. thereby creating an oval window baffle. In all of these procedures the aim was to aerate the middle ear by the Eustachian tube. Type 5. This was difficult to achieve because the repaired tympanic membrane often became atelectatic and adherent to the medial wall of the middle ear. A sixth was added by Garcia Ibanez in 1961. 4. transmits sound from the tympanic membrane to the labyrinth. The footplate is exteriorized by leaving it exposed in the created mastoid cavity. however. it became evident that an intact ossicular chain was important to achieve consistently good air-bone closure. the columella. 2. In addition. The tympanic membrane is reconstructed to lie on the stapes head to create a columella effect (myringostapediopexy). The round window is acoustically separated from the oval window by reconstructing the tympanic membrane so that its superior margin lies on the promontory below the oval window. They are. Otherwise known as sono-inversion. 3. Type 2. Reconstruction of the tympanic membrane with an intact and mobile ossicular chain. The round window niche is left uncovered and the tympanic membrane reconstructed so that its inferior edge lies on the promontory above the round window. often used synonymously. Type 1.

1983. There are several possible scenarios in reconstruction. Follow-up and aftercare The ear canal dressing is removed after 7–14 days. Related topics of interest Mastoid surgery. An incudostapediopexy using a cortical bone slither or a ceramic prosthesis as an incus-to-stapes assembly are the preferred methods of reconstruction. p. Closure of the air-bone gap to within 20 dB has been reported in up to 80% of patients using ceramic PORPs and 50% of patients using TORPS. A stapes footplate remnant is present with or without the malleus. The Netherlands: Martinus Nijhoff Publishers. 2. p. 24: 168–171. Theory and practice of tympanoplasty. . 35. Further reading Wullstein H. An alternative is to use biodegradable porous hydroxyapatite tricalcium phosphate ceramics which have been shown to be replaced at least in part by osteogenic cells and host connective tissue. Laryngoscope. 38. Cholesteatoma.g. A myringostapediopexy or malleostapediopexy is performed using an autograft or ceramic total ossicular replacement prosthesis (TORP) to create the tympanic membrane or malleus-to-footplate assembly. An autograft malleus-to-stapes assembly (incus transposition) or a ceramic partial ossicular replacement prosthesis (PORP) is used. Clinical Otolaryngology. although some otologists allow both in the first post-operative week. Causse) advocate performing the Valsalva manoeuvre in the early postoperative period to achieve the same aim although there is a theoretical risk of displacing the prosthesis.342 OTOLARYNGOLOGY Ossicular chain reconstruction Homograft tissue is now contraindicated because of the risk of CJD. but there have been recent concerns regarding long term failure of the prostheses due to late fractures of the ceramic. p. Biomaterials in otology. There is an incudostapedial discontinuity secondary to an absent lenticular process and/or stapes head. Kerr AG and Riley DN. Autograft reconstruction using cortical bone or remodelled incus is now usually preferred. 1999. Nasal decongestants may improve Eustachian tube function in the short term and help ensure aeration of the middle ear cleft. Grote JJ. Proceedings of the First International Symposium 1983. Exertion and flying should be avoided until healing is achieved at 4–6 weeks. Chronic suppurative otitis media. Diving may predispose to prosthesis displacement and should be avoided. 1956. The stapes superstructure is intact but there is an absent long process of incus. The malleus handle may or may not be present. Disintegration of porous polyethylene prostheses. To minimize extrusion of the ceramic implants some authorities recommend a slither of autograft tragal cartilage is interposed between the tympanic membrane and prosthesis. 1. Leiden. 159. Swimming is contraindicated until healing is complete. Some authorities (e. 3. 66:1076–1093. Porous polyethylene prostheses introduced by Shea in 1976 have produced results similar to hydroxyapatite.

It has been well established that the pathological changes of tympanosclerosis are situated in the lamina propria. The second stage is the reparative phase. Pathogenesis Three stages are recognized. Otoscopically. with very large plaques and . inflammatory processes cause an exudate. however. tympanic cavity and occasionally in the mastoid. It may occur in all age groups. Clinical features It has been suggested that the term myringosclerosis be used when the process is confined to the tympanic membrane and the term tympanosclerosis be exclusively reserved to describe sequelae of chronic otitis affecting the ossicular chain. varying in size. characterized by calcareous deposits in the tympanic membrane. However. Tympanosclerosis that is restricted to the tympanic membrane is most commonly seen. even with quite extensive plaques.TYMPANOSCLEROSIS Tympanosclerosis is an abnormal condition of the middle ear. this may be due to intraepithelial haemorrhage. the occurrence of plaques in the tympanic membrane may indicate the presence of more extensive disease in the middle ear in patients with a history of chronic otitis. Most authorities now consider the process to be irreversible. Aetiology The exact cause remains in doubt. 1. In most cases there is little if any effect on the patient’s hearing. usually following myringotomy and ventilation tube insertion. but it appears likely that there is an abnormal healing process in response to multiple acute or chronic inflammatory episodes. chalk-like material. In the initial stage. as a result of which fibres become indistinct. Plaques usually occur only in the pars tensa. the formation of granulation tissue and damage to collagen fibres. This phase is generally considered reversible. characterized by fibroblast invasion. Morphologically. which is substantiated by the frequent occurrence of tympanosclerosis after myringotomy with or without insertion of ventilation tubes. and in the third and final stage calcification and occasionally ossification may occur. no differentiation can be made between the two conditions. deposits present as sharply demarcated areas of white opaque. Another important aetiological factor is tissue trauma. This results in excessive collagen synthesis and hyalinization. which is the connective tissue component of tympanic membrane and mucosa. The clinical importance of this calcification is dependent on its size. fusing into a homogeneous mass. Furthermore. mostly situated in the anterior or posterior segments. Tympanic membrane.

Tympanoplasty. The condition tends to be most prevalent in the oval window niche. These patients often have a significant hearing loss. 1993. There is. The choice of procedure depends on the extent of middle-ear involvement but may include stapedectomy and/or attic mobilization or clearance. Follow-up and aftercare This should be appropriate to the patient’s surgery and any active otological pathology. 2. Middle-ear. . epitympanum and promontory. p. In cases of tympanosclerosis the involved ear is usually dry with a large central perforation. 35. Furthermore. p. A hearing aid is safe and effective. Examination under a microscope will nearly always resolve the issue.344 OTOLARYNGOLOGY those that impinge across the annulus. Otitis media with effusion. Kerr AG. Clinical Otolaryngology. these ears are often dry. a natural tendency for resolution in this group. Investigation The clinical appearance of tympanosclerosis in either the middle-ear cavity or tympanic membrane rarely presents any diagnostic difficulties although it may occasionally look like a cholesteatoma. Occasionally removal of a plaque may be required during myringoplasty. whereas in an ear with cholesteatoma the perforation or retraction pocket is usually marginal and often there is malodorous otorrhoea. which is invariably due to fixation of the ossicular chain. p. but when it occurs is usually accompanied by a perforation of the tympanic membrane (85–100%). for a coexistent perforation. Management Tympanic membrane tympanosclerosis with an intact drum rarely requires treatment. Related topics of interest Cholesteatoma. 18:341–349. 341. An audiogram to assess any degree of (conductive) hearing loss is always useful. Middle-ear involvement is much less common. Tympanosclerosis (review). Studies that show initial improvement in hearing also demonstrate a deterioration in hearing levels with time. The patients are usually over 30 years of age and have had a long history of ear problems. 213. Conductive hearing loss caused by tympanosclerosis can be treated with either a hearing aid or surgery. it has been shown that a number of patients suffer a postoperative sensorineural hearing loss. to aid healing. however. measurable hearing loss may result (20–40 dB). The condition occurs in approximately 5% of children with otitis media with effusion who have had no previous surgery. surgery is controversial. Further reading Wielinga EWJ. Interestingly.

Central disease includes cerebrovascular disease. 15% from proprioception and 15% from the vestibular system. These are membranous tubes within the dense temporal bone. The neck and ankles are the most important proprioceptive inputs. The membranes are fluid filled and have cells with cilia which bend as the fluid moves relative to them. Vestibular disorders are either central or peripheral. metabolic.Lesser Definition Vertigo is the hallucination of movement. loss of memory and anxiety that are associated with vestibular disorders. It is the cardinal symptom of disease of the vestibular system including its central connections. multiple sclerosis. migraine. The brain stem computerizes these three inputs and with the help of the cerebellum maintains the balance and co-ordination of the head and body. musculoskeletal or ocular disease may cause dizziness or a sense of light-headedness. Approximately 70% of balance is due to visual input. though not usually vertigo. It also. The. This excites or depresses the nerve cells and alters the tonic input into the brain. Sir Terence Cawthorne said that ‘labyrinthine disturbance may make one feel like the end of the world has arrived and I am told by sufferers from sea sickness that in the acutest phase of their distress they wish that it had’. The semicircular canals are at right angles to each other and detect changes in angular acceleration. Remembering this enables us to understand the distress of these patients. The last hardly ever causes vertigo as a presenting symptom. Here they are integrated with two other inputs that enable us to balance. These are secondary effects from the vertigo and often remain after the vertigo has gone.VERTIGO T. Anatomy and physiology The vestibular sense organ consists of the three semicircular canals. the saccule and the utricle. skin and muscle receptors. explains the many symptoms such as muzzy head.J. two other inputs are vision and proprioception. When this basic system goes wrong. The ‘sense’ of balance is very basic and phylogenically predates sight and hearing. The nerve impulses from the labyrinth go to the vestibular nuclei in the brain stem. the patient is left disabled. The utricle and saccule have otoconia embedded in a gel overlying the cilia and are positioned to detect linear acceleration. Pathology and clinical syndromes Non-vestibular disorders such as cardiovascular. from the joints. brain tumours and very rarely vertebrobasilar insufficiency. . in combination with the very basic nature of the sense of balance.H.

visual phenomena. but this is often accompanied by tinnitus and occasionally there is a non-specific dizziness. The patient is told to keep their eyes open and look straight ahead. as can inner ear infections such as syphilis. The patient is asked if this provokes symptoms similar to those they have been describing and the eyes are observed for nystagmus. associated symptoms (e.g. 30° below the horizontal. vertigo and tinnitus. dysarthria. neck movements). An otological and neurological examination is mandatory in all cases of vertigo. Middle-ear disease such as cholesteatoma can also cause vertigo. Previous medical history. claustrophobia. tinnitus) and frequency and duration of the attacks. with their head over the edge of the bed.g. There are no other otological manifestations. Non-organic dizziness and vertigo also exist and may be associated with hyperventilation. Acute vestibular failure consists of marked vertigo for many hours or days often preceded by an upper respiratory tract infection. light-headedness. deafness. It is diagnosed by the Hallpike manoeuvre. A general medical examination may be required if the symptoms dictate. 2. Menière’s syndrome comprises paroxysmal fluctuating hearing loss. The patient is positioned sitting on a bed and the procedure is explained. medication. The Hallpike manouvre Positional nystagmus is best elicited by this positional test. of which there are three main symptom complexes. A previous history of trauma should be noted. co-trimoxazole. and alcohol ingestion should also be considered in the context of possible causes or aggravation of the symptoms. Benign positional vertigo commonly occurs after a head injury or ear infection and is a rotatory vertigo with a particular head movement. 3. if the vertebral or basilar artery is constricted. latrogenic vertigo caused by drugs (aminoglycosides. A full description of the sensation should be obtained with reference to precipitating factors (e.346 OTOLARYNGOLOGY Indeed. we are left with the peripheral causes of vertigo. The head is held firmly between the examiner’s hands and turned 45° to the right or left. The patient is then rapidly laid backwards. Benign paroxysmal positional nystagmus elicited by the Hallpike manoeuvre usually has a latent period of 5 seconds before the onset of rotatory nystagmus. or some peripheral (musculoskeletal) dysequilibrium. Cervical vertigo frequently occurs and is more likely to be due to disordered proprioceptive input from the neck. In particular middle-ear disease is looked for and nystagmus on finger following or after the Hallpike test. Gait assessment including Romberg’s and Unterburger testing is important (see Vestibular function tests). 1. If no symptoms or nystagmus are elicited the process is repeated but with the head to the other side. These causes aside. Acoustic neuroma usually presents with a unilateral sensory hearing loss. Clinical features It is often difficult for patients to describe their sensations. diuretics. If neither occurs after 30 seconds then the patient is returned to the upright position and again asked if there is any vertigo and the eyes examined for nystagmus. a fast component to the nystagmus directed towards the . each attack lasting many minutes or hours. diplopia and weakness of one side of the body are usually the presenting signs. This explanation should include a reassurance to the patient that they will not be allowed to fall whatever happens. and in taking a full and accurate history the symptom of vertigo must be differentiated from other types of dizziness such as fainting. metronidazole) is common due to either ototoxicity or a central effect.

g. or antidepressants. less alcohol) and drugs. histamine analogues such as betahistine. optokinetic and positioning stimulation. This is usually used for episodic peripheral vertigo diagnosed as Menière’s syndrome and consists of endolymphatic sac shunting. . 2. With adequate counselling as many as 80% of patients with vestibular disorders will benefit from vestibular rehabilitation to encourage vestibular compensation. Further reading Luxon LM. p. The Epley (liberatory) manouvre works as a single treatment in up to 80% of patients. causes little or no vertigo and persists indefinitely if the head position is maintained. These allow a new equilibrium situation to occur. it is very unlikely that head positioning or neck extension has any role in the cause of the patient’s vertigo. London: Arnold.VERTIGO 347 undermost ear. Related topics of interest Acoustic neuroma. vestibular neurectomy or labyrinthectomy. Caloric tests. Management 1. Cholesteatoma. p. evoked response audiometry. This contrasts with nystagmus of central origin. The latter are usually vestibular sedatives such as prochlorperazine or cinnarizine. This is now considered to be the mainstay of treatment in many vestibular disorders. It is known that structural changes occur to allow vestibular compensation such as a modification of the distribution and sensitivity of cholinergic synapses. Vestibular function tests. p. Chronic suppurative otitis media. 244. Vestibular rehabilitation. patients may also benefit from spectacles to improve their visual acuity or a walking stick to aid peripheral balance function and to give them more confidence. an associated vertigo which distresses the patient. and posturography (see Related topics). Occasionally surgery is used for benign positional vertigo when posterior semicircular canal obliteration or singular neurectomy is done. Brandt-Daroff exercises encourage habituation and succeed in 95% of cases when used with determination. Medical treatment. which appears immediately. Specific manouvres and exercises are used for BPPV. p. Ludman and Wright (eds). 350. 1998. 35. In: Diseases of the Ear. This consists of lifestyle changes (e. 27. 1. The first step is to counsel the patient regarding their symptoms. This is followed by a series of habituating exercises performed regularly to enable tolerance mechanisms to occur in the brain stem. Surgery. and the nystagmus fatigues rapidly. 6th edn. 38. Rehabilitation and management of balance and vestibular disorders. to provide reassurance and to explain the importance of persisting with treatment. Investigations Vestibular testing consists of pure tone audiometry. Perilymph fistula. A middle-ear infusion of an aminoglycoside via a cannula in the round window is used by some. MRI with gadolinium enhancement is the radiological investigation of choice. p. p. 233–241. 3. In addition to vestibular rehabilitation. electronystagmography with caloric stimulation. If there are no symptoms or nystagmus after the Hallpike manoeuvre.

the central nervous system and the locomotor system. Smooth pursuit This system is responsible for maintaining gaze on a moving target. care must be taken in the interpretation of vestibulo-ocular responses. separated either horizontally or vertically. Clinically. The central vestibuloocular and visuo-ocular pathways are intimately related. Bilaterally impaired smooth pursuit is usually a non-specific abnormality observed in a fatigued patient or one who is on certain . Saccades Saccades are rapid eye movements. Saccadic eye movements may be assessed by asking the patient to look back and forth between the examiner’s index fingers. However. (2) the eyes and (3) the proprioceptors in the muscles of the limbs. A comprehensive history is essential. accuracy or velocity of saccades. with particular attention to the eyes. It may be examined clinically by asking the patient to follow a pendulum swinging from side to side.g. These sensory organs connect directly with the brain stem and the cerebellum and then with the cerebrum. The clinical correlate of this is that the assessment of any disorder of disequilibrium must be based on a multidisciplinary approach. and both pathways share the common final pathway of the oculomotor nerve. trunk and neck. tests based on (a) the vestibulo-ocular reflex and (b) vestibulospinal reflexes can be performed. it is necessary to identify the presence or absence of a vestibular component. Central nervous system disease may cause abnormalities of latency. by comparing the eye velocity with that of the target velocity and producing a continuous match of eye and target position. Tests of the vestibulo-ocular reflex lex Eye movements are generated in response to visual signals and vestibular activity. the ears. If visually controlled eye movements are normal (e.VESTIBULAR FUNCTION TESTS An individual maintains balance by coordinating sensory information provided by (1) the vestibular system. and bring the desired object of fixation to the fovea in the shortest possible time. which correct errors in the direction of gaze. if visually controlled eye movements are abnormal. derangement of the vestibulo-ocular reflex may correctly be ascribed to vestibular dysfunction. saccades and the smooth pursuit system). Having established the need for a general medical approach to the problem of unsteadiness. together with a complete general medical examination.

and then up and down. Ocular nystagmus. Vestibular nystagmus can be spontaneous or positional. This consists of a slow movement of the eyes in one direction followed by a quick return in the opposite direction. A nystagmus which is not associated with vertigo and does not fatigue is more likely to be associated with a central lesion. A nystagmus which is fatiguable and short-lasting is usually associated with a peripheral pathology (e. . Basically. antidepressants. This tends to be pendular. anticonvulsants or benzodiazepines). It will be present in the majority of normal individuals if the irises of the eyes are deviated horizontally further than the punctum of the lacrimal sac: an important point to remember when testing for spontaneous nystagmus. The fast component. e. 1. Increasing degrees of severity of spontaneous nystagmus are recognized. The test has the disadvantage of stimulating both labyrinths simultaneously. 2. Vestibular nystagmus. • Physiological nystagmus refers to nystagmus observed in normal subjects. Congenital nystagmus is present from birth. or recovery movement. a nystagmus whose quick component is to the right is called a nystagmus to the right. tests for positional nystagmus are done in the upright and supine positions with the head turned to either side. and it has found limited clinical application. Nystagmus Nystagmus is an involuntary. Thirddegree nystagmus is still present when the patient looks in the direction of the slow component. Second-degree nystagmus is present when the patient looks straight ahead. The direction of the nystagmus is named according to the direction of the fast component.g. benign paroxysmal positional vertigo). • Pathological nystagmus may be congenital or acquired. It can be either physiological or pathological. Unilateral impairment is a more reliable marker of central nervous system pathology.g. (b) Positional nystagmus is usually rotatory and accompanied by rotatory vertigo. Acquired nystagmus is described as ocular. followed by a return of the eyes to their original position. The slow component is produced by impulses from the vestibule. It is common in congenital blindness. Miner’s nystagmus is a form of the ocular variety. Nystagmus is most marked when the patient looks in the direction of the fast component and is lessened or abolished when looking in the direction of the slow component. (a) Spontaneous nystagmus can be elicited by asking the patient to follow a finger held 60 cm away to the left and then the right.VESTIBULAR FUNCTION TESTS 349 medication (alcohol. vestibular or central in origin. rhythmical oscillation of the eyes away from the direction of gaze. but may occur without any defect of vision. The test is also criticized because the stimulus is considered excessively violent. The nystagmus induced by acceleration and deceleration in a rotating chair is recorded. is a central correcting reflex. It is nearly always dependent on optic fixation and so disappears when this is removed by asking the patient to wear Frenzel’s glasses. Specific tests based on the vestibulo-ocular reflex 1. Rotation tests. Positional testing is described in detail elsewhere. Physiological nystagmus can also be induced by thermal (caloric) or rotational stimulation. First-degree nystagmus is present only when the eyes are deviated in the direction of the fast component.

Body rotation of more than 30°. and after amplification are recorded permanently on a moving paper strip. but the most commonly used are force platforms. and caloric tests. . The patient may fall towards the side of a recent peripheral vestibular lesion. Romberg test The Romberg test is used to assess a patient’s ability to stand. Full ENG testing includes a series of tests including different head positions. with eyes closed and arms outstretched in front. A hemiplegic gait. 3. Clinically vestibulospinal function is tested by examining stance and gait. arms by the side. or high stepping gait with loss of proprioception may become apparent. this remains a popular investigation. cerebellar ataxic gait. This technique is based upon the positive potential which exists between the cornea and retina. The data have enabled the effects of various sensory modalities upon balance to be identified. In contrast. feet together. and some claim they allow various pathological conditions to be differentiated. In spite of improved imaging of the temporal bone and the advent of evoked response audiometry.350 OTOLARYNGOLOGY 2. Posturography is the recording of postural sway. Electrodes are attached to the skin at each outer canthus close to the eyes. eyes open and closed. Several techniques have been used to evaluate such postural stability. With eye closure some patients with uncompensated vestibular lesions will veer towards the affected side. or forward or backward displacement of more than 1 metre. A few of the more recent platforms have been used to rehabilitate patients with balance dysfunction by way of visual feedback. Parkinsonian shuffle. Test of the vestibulospinal reflex Tests based on the vestibulo-ocular reflex are regarded as the most essential part of the investigation of the vestibular system. with hands clasped together. Gait testing Gait is assessed by watching the patient walk normally with eyes open and then closed. Changes in the corneoretinal potentials are recorded at the electrode sites as the eyes move from straightahead gaze. tests of vestibulospinal function are commonly neglected in the evaluation of patients with balance dysfunction. It is also a popular topic in the Fellowship examination (see Caloric tests). The changes in electric potential are used to follow nystagmus. Caloric tests. The high cost of many balance platforms has prohibited their use in both research and clinical practice. Specific tests based on the vestibulo-spinal reflex Objective balance assessment has potential clinical use in the investigation of dizzy patients as a complement to existing tests. is regarded as abnormal. Unterburger test This is performed by asking the patient to walk up and down on the spot for 30 seconds. Electronystagmography (ENG). with eyes open and then closed.

87–104. 1993. Vertigo. 1: 35–39. Current Opinion in Otolaryngology and Head and Neck Surgery. p. Vestibular function analysis. Schwaber MK. . 1998. p. Davies R. 6th edn. Related topics of interest Caloric tests.VESTIBULAR FUNCTION TESTS 351 Further reading Omahoney CF. Vestibular investigations.) London: Arnold. In: Diseases of the Ear. 346. Ludman H and Wright T (eds. 27.

Pathology A vocal cord palsy may be unilateral or bilateral. which is sensory to the laryngeal mucosa above the vocal cords. e. e.g. and the movement the cords cannot initiate is described as an adductor or an abductor palsy. The vagus gives two important branches for voice production: the superior and the recurrent laryngeal nerves. 1.g. and the internal laryngeal nerve.g. looping around the subclavian artery to reach the tracheo-oesophageal groove. e. The nerve enters the larynx below the cricoid cartilage and the lateral origin of cricopharyngeus and so cannot be injured above this level. (3) The intrinsic muscles which move the vocal cord. There are two theories describing the position of the vocal cord. The superior laryngeal nerve branches into the external laryngeal nerve. In practice. a low lesion of the recurrent laryngeal nerve will allow the vagus to exert an overall abductor effect on the vocal cord. The Wagner-Grossman theory proposes that. The cord should lie in a median position if this were true. supplying the cricothyroid muscle. How-ever with a lesion affecting the origin or above of the superior laryngeal nerve. The recurrent laryngeal nerve arises high in the chest on the right. Semon’s law states that. for any lesion affecting the recurrent laryngeal nerve. . a myopathy or infiltration by a malignancy. 2. A vocal cord palsy may arise from pathology of: (1) The recurrent laryngeal nerve. but on the left arises at the level of and looping around the aortic arch to reach the same groove. because the superior laryngeal nerve supplies the cord adductor cricothyroid. the fibres supplying the adductors are more susceptible to injury. rheumatoid arthritis. It supplies the remaining intrinsic laryngeal muscles and is sensory to mucosa below the cords. recurrent laryngeal nerve palsy accounts for the majority of cases. the cord will lie in the cadaveric position. pressure damage or a neuropathy. a cord adductor. The fact that a cord palsy caused by a left apical bronchial carcinoma produces a median positioned cord somewhat discredits this theory. iatrogenic. (2) The cricoarytenoid joint.VOCAL CORD PALSY Anatomy The roots of the vagus emerge from the pons and medulla to gain a trunk and exit the skull through the jugular foramen. neither of which is entirely satisfactory.

any improvement in voice will be at the expense of the airway. 4. Orton’s syndrome and inflammatory disease. Speech therapy may be helpful.VOCAL CORD PALSY 353 Aetiology 1. Idiopathic (15%) in which no cause is identified but which may be related to infection with a neuropathic virus. Bilateral adductor palsy. • An anterior. Evaluation of the paralysis itself is assessed during phonation and respiration. myopathies. ideally using videostroboscopic endoscopy. which is injected just lateral to the vocalis muscle at two sites: just anterior to the vocal process and midway between this and the anterior commissure. When the cause is idiopathic or there is a chance of spontaneous resolution. or a permanent tracheostomy. Further investigations are then chosen as appropriate to the underlying cause. 3.g. Symptoms related to the cause may be present. Unilateral abductor palsy. Stridor suggests a bilateral abductor palsy. Speech therapy can be helpful to achieve compensation. from road traffic or sporting accidents and stab or gunshot injury. oesophageal.g. External trauma (15%) e. Bilateral abductor palsy. Investigations A CT scan from the skull base to the aortic arch is the first and most useful investigation. so judgement is required to achieve the optimum compromise. pharyngeal pouch and left lung surgery. Woodman’s operation) or a suture technique (e. Aspiration can occur with any palsy if the sensory supply to the larynx is compromised. posterior thyroplasty (e. Unilateral adductor palsy. Treatment consists of a cord medialization procedure which includes: • Injection of Teflon (available on a named-patient basis as it may cause granulation tissue formation) or a collagenase-resistant collagen (e. such as haemoptysis or dysphagia. .g. 2. 2. Others (15%) e. thyroid and nasopharynx. Management 1.g. Most patients will aspirate and often the cause is a neurological or myopathic disorder so that medialization procedures do not usually help the cause. A permanent tracheostomy or even a laryngectomy as a last resort may be required. 3. a wait of at least a year is necessary. Malignant disease (30%) especially of the bronchus. neurological disorders. 4.g. oesophagus. In most cases no treatment is necessary because the normal cord compensates to produce a near-normal voice which tires with use. latrogenic (25%) especially thyroid and parathyroid. Others are stridulous and the treatment options are: an endoscopic laser cordectomy or arytenoidectomy or both. A neuromuscular pedicle procedure using the ansa cervicalis and a strap muscle has been described (by Tucker) but has not been widely adopted. Many patients surprisingly are not stridulous unless they develop an upper respiratory tract infection. external thyroplasty (e. For surgical treatment. GAX collagen). A voice which becomes weak or hoarse with use suggests an abductor palsy or a compensated adductor palsy.g. 5. Isshiki). Downie’s arytenoidoplasty). Clinical features A breathy voice with a poor cough suggests an uncompensated adductor palsy.

The timing of surgical intervention in vocal cord paralysis. Human laryngeal reinnervation. Laryngoscope. 1981. Stridor and stertor. 336. (b) To observe spontaneous resolution. p. . p. Otolaryngology and Head and Neck Surgery. p. 147.354 OTOLARYNGOLOGY Follow-up and aftercare This is required: (a) To exclude an occult carcinoma. Aftercare will be necessary for those patients requiring a tracheostomy. Related topics of interest Lasers in ENT. Further reading Tucker HM. Miller RH. 311. 89:264–267. Woodson GE. 86:769–779. (c) To enable a stable situation to be reached with regard to the voice and airway. 1976. Tracheostomy.

244 Beta blockers. 11 Audit. 50–51 Auditory response cradle. 292 Cervical lymphadenopathy. 230 Atopy. 49–52 Cluster headache. 276 Acoustic neuroma. 276 Allergic rhinitis. 53–58 complications. 228–229 Anaesthesia general. 257 Bekesy audiometry. 230 Bárány noise box. 39. 220. 25 Choanal atresia. 33 Cacosmia. 29–32 Chemodectomas. 23–26 Benign positional vertigo. 59 conductive. 60 Blepharospasm. 79–80 Bucconasal membrane. 95 Benign neck lumps. 38 Cisplatin. 117 Beta2-transferrin. 47 Bing-Siebenham dysplasia. 256 Bell’s palsy. 257 Cooksey-Cawthorne exercises. 9 Clinical assessment of hearing. 347 Bezoid’s abscess. 288 Anticonvulsants. 60. 288 Caloric tests. 92 Bobbing oscillopsia. 25 Cavernous sinus thrombosis. 45 Barium swallow. 129 Acquired immune deficiency syndrome (AIDS). 11–13 Aminoglycosides. 19–22 toxicity. 38–41 atticoantral. 229 Branchial cyst. 276 Adenoids. 98–99 Cochlear implants. 19–20 Angiofibroma. 6 Bing test. 60 Constant positive airway pressure (CPAP). 59–61 autosomal dominant. 24 Brain stem electrical response audiometry. 61 congenital sensorineural. 221.INDEX Acinic cell carcinoma. 59 autosomal recessive. 27–28 Carhart effect. 121 Acute suppurative otitis media. 94. 240 Automatic gain control. 51–52 research and. 8–10 Adenoid cystic carcinoma. 57–58 Common chemical sensation. 230 Citellis abscess. 136 . 224 Carotid body tumour. 45–48 Clinical governance. 257–258 Conditioned reflex audiology. 6 Cleft palate. 299 Contrast swallow. 49–52 National. 33–34 Cholesteatoma. 5. 183 Anosmia. 5–7 Adenocarcinoma. 255 Carhart’s notch. 39–40 complications. 35–37 Chronic suppurative otitis media. 1–3 Acoustic reflex measurement. 14–18 local. 42–44 tubotympanic.. 29 Computerized tomography. 240 Congenital hearing disorders.

73 Eustachian tube. 230 Day case ENT surgery. 25 Glomus vagale. 13 Distraction testing. 36. acute. 195 De Quervain’s thyroiditis. 241 Examination of the ear. 92 Hemilaryngectomy. 73 Fissula ante fenestram.356 INDEX Cordectomy. 183 Erythroplakia. 308 Ear wax.220 Cystic fibrosis. 80–81 Cosmetic surgery. 247 Dysphagia. 25 Glue ear. 78–81. 82–83 of the nose. 214 Gustation. 317 Headache. 73 Herpes zoster. 78–79 Electrolarynx. 144 Hereditary haemorrhagic telangiectasia. 133 indications. 104–105 trachea and bronchi. 70–71 Epistaxis. 103–107 ear. 117–120 body-worn. 134 Foreign bodies. 213 Evidence based medicine (EBM). 92–93 CSF leak. 67–69 Decibel. 203 Ethmoidal artery ligation. 105–106 pharynx. 115–116 Hallpike manoeuvre. 171–172 Hitselberger sign. 121–123 . 89 Epstein-Barr virus. 101 oesophagus. 118 implantable middle ear. 75–77 Evoked response audiometry. 100–101 Higginson’s syringe. 221 Hashimoto’s thyroiditis. 86–88 Exostoses. 347–348 Halo sign. 316–318 Grave’s disease. 89–91 Facial myokymia. 119 design. 294 Hair transplantation. 144 Corneal reflex. 34 Desensitization. 174 Cytotoxic agents. 145 Endolymphatic hydrops. 82 External ear conditions. 195. 117–118 in the ear. 213–215 Goitre. 113–114 Glomus jugulare. 64–65 Familial haemorrhagic telangiectasia. 119 ITE or ITC. 108–109 surgical technique. 97–102 Hearing aids. 167 Epiglottis. 118 spectacle. 28 Functional endoscopic sinus surgery. 63–66 Craniofacial resection. 92–96 Facial pain. 2 Cortical electrical response audiometry. 223 Fistula sign. 84–85 of the throat. 317 Dermoid cyst. 119 Hemifacial. 103–104 nasal. 254–255 Delayed speech feedback. 119 osseointegrated. 89–90 Electrocochleography. 240 Dohlman’s procedure. 119 postaural. 219. 92 Facial nerve palsy. 65 Halitosis. 108–112. 13 auto-inflation. 317 Grommets. 72. 2 HIV infection. 90 High grade T-cell lymphoma. 106–107 Free tissue transfer. 306–307 Dysphonia. 214 dysfunction. 118 bone conduction. 109–110 Globus pharyngeus. 269 Frenzel’s glasses. 72–74 Epithelial migration. 304 Electronystagmography. 97–102 Facial reanimation. 352 Emergency laryngectomy. 90 External auditory canal. 178–179. 283 Crocodile tears.

281 Oncocytoma. 138–142 Laryngectomy. 99 Myringoplasty. 229 Ludwig’s angina. 98 Mondini’s dysplasia. 87 Induced hypotension. 232. 42. 190 Lymphangiomas. 119 Ossicular chain reconstruction. 7. 144–145 total. 186–187 Neck space infection. 282–283 Kaposi’s sarcoma. 187 radical. 203–205 Osseointegration. 147–150 Lateral rhinotomy. 134–137 Laryngeal carcinoma. 33 Nasal polyps. 51–52 National Confidential Enquiry into Perioperrative Deaths (NCEPOD). 276 Oral cavity carcinoma. 169 Labyrinthine fistula. 275 Mucocele. 203 Literature evaluation. 144 supracricoid partial. 90 Kiesselbach’s plexus. 289 Myofascial headache. 84–85 Nasal granulomata. 185–186 selective. 341 Nasal cavity. 233 Laser assisted uvulopalatoplasty (LAUP). 175 Nasal trauma. 72 Killian’s dehiscence. 73 Medicolegal issues in ENT surgery. 350–351 Oseophageal voice. 151–158 Loop diuretics. 180–184 Nasopharynx. 159–161 Maxillary artery ligation. 24–25 Laryngograph. 206–208 Otitis externa. 143–146 emergency. 60 Migraine. 25 Nitrous oxide. 162–166 Menière’s disease’s. 347 Michel’s deformity. 174–176 antrochoanal. 6. 194 Indirect laryngoscopy. 180–182 Nasopharyngeal tumours. 15–16 Noise-induced hearing loss. 85 National audit. 122 Kemp. 170–173 Nasal placodes. 281 Masking. 317 Hypopharyngeal carcinoma. 233 Laryngotracheobronchitis. 342 Osteoma. 246 Labyrinthectomy. 8 Leucoplakia. 23 Magnetic resonance imaging. 145 supraglottic. 124–127 Impedance audiometry. 13. David. 304–305 Olfaction. 276 Mycetoma. 128–130. 134 Labyrinthitis. 36. 167–169. 60 Monomorphic adenoma. 192–193 medicolegal aspects. 209–212 . 185–187 bilateral.INDEX 357 Hoarseness. 145 hemi-. 131–133 Inverted papilloma. 197–200 Oroantral fistulae. 283 Lateral sinus thrombosis. 194–196 Nystagmus. 216 Keratosis obturans. 291–292 Otalgia. 159–161 cortical. 309 Laryngomalacia. 145 Laryngocele. 258–259 Malignant melanoma. 159 modified radical. 294 Olfactory neuroblastoma. 16 Intrinsic rhinitis. 188–191 Neurofibromas. 51 Neck dissection. 193 Non-organic hearing loss. 299 Lasers in ENT. 177–9 Nasopharyngeal carcinoma. 232–233 Hyperthyroidism. 42 Lateral soft-tissue radiograph. 90 Osteomyelitis. 292–293 Mucoepidermoid carcinoma. 255–256 Mastoidectomy. 201–202 Oropharyngeal carcinoma.

350 Salicylates. 354 Semicircular canals. 226 Semon’s Law. 289–290 Sjögren’s syndrome. 256 Pure tone audiometry. 60 Scleroma. 271 Skin tests. 47 ‘Roll over’. 15 Presbyacusis. 9 Rhinoplasty. 322–323. 241 distortion product. 232–236 endoscopy. 25 Schwartze’s sign. 239–241 Palliative care. 190 tumours of. 226 Ototoxicity. 25–26 Peak clipping. 126.358 INDEX malignant. 82 Sinonasal tumours. 264–266 Ramsay-Hunt syndrome. 178 Septal perforation. 252–253 Prevertebral abscess. 271 Siegle speculum. 301 Photodynamic therapy. 244–245 Permanent threshold shift. 42 Pharyngeal pouch. 280–284 Sinusitis. 352 Saccades. 172–173 Schwannoma. 278–279 Sialectasis. 294–296 Smooth pursuit. 240. 150 Photon. 237–238 hearing assessment. 285–287 chronic. 101 Premedication. 267–270 Retraction pocket. 257 Platinum-iridium alloy. 12 Radiology for ENT. 249–251 Pharyngoplasty. 115 Salivary gland disease. 9 Phonemes. 12 Smell and taste disorders. 216–217 Otological aspects of head injury. 27 Septal haematoma. 76 Reconstructive surgery. 271–273 Salivary gland neoplasms. 285–290 acute. 216–217. 189 Proprioception. 216 transient evoked. 218–220 Otorrhoea. 95 Randomized control trials. 302 Romberg test. 228–231 Paediatric airway problems. 274–277 Scheibe dysplasia. 213–215 Otoacoustic emissions. 346 Provocation tests. 221–222 Otosclerosis. 63–64 Plain film. 317 Rinne test. 35 Retropharyngeal abscess. 134 Perilymph fistula. 298 Postherpetic neuralgia (PHN). 217 spontaneous. 141 Papillary adenocarcinoma. 254–256 computerized. 189 Rhinolalia aperta. 65–66 Riedel’s thyroiditis. 230 Saliva. 194 Quinine. 291–293 fungal. 54 Pleomorphic adenoma. 275 Polysomnography. 192 Petrositis. 275 Papilloma of the larynx. 223–227 cochlear. 172–173 Rhytidectomy. 271 Pure tone audiogram. 117 Perilabyrinthitis. 63 Rhinospondiosis. 12 Pseudoparotomegaly. 135 Parapharyngeal space. 297–300 . 287–290 complications. 242–243 Paralabyrinthitis. 230 Radioallergosorbent test (RAST). 350 Snoring and obstructive sleep apnoea. 82 Pinnaplasty. 246–248 Pharyngocutaneous fistula. 94. 211 Otitis media with effusion. 216 stimulus-frequency. 147 Pinna. 257–262 Radiotherapy. 188 abscess. 325 Papillary cystadenoma.

226 Static compliance. 3 Stridor and stertor. 54 Speech discrimination tests. 172 Telecanthus. 130 Stenger test. 301–303 Speech coding. 259 Unterburger test. 276 Stapedectomy. 352 Video stroboscopy. 316–321 malignant. 203 T-tube. 99 Tension headache. 233–234. 313 Subglottic stenosis. 346–349 Vestibular failure. 314–315 Synkinesis. 47–48 Stereotactic radiosurgery. 339 tubes. 304–307 in non-malignant voice disorders. in head and neck surgery. 92 Syphilis. 337 Tragal rub. 240 Speech therapy. 134 Tuning forks. 299 Speech audiometry. 308–310 Split skin grafts. 23–24 Thyroid disease benign. 268 Zenker’s diverticulum. 84 Thyroglossal cyst. 336–340 decannulation. 338 percutaneous. 190 Sudden hearing loss. 45–46 Wagner-Grossman theory.INDEX 359 Somnoplasty. 299 Vertigo. 194 Tympanic membrane. 192 Temporomandibular joint dysfunction. 214 Tuberculosis. 232. 246 . 170–171 Wolfe graft. 327–329 Tonsillectomy. 275 Weber test. 330–332 Tracheostomy. 161 Tympanosclerosis. 100 Trismus. 326 Tinnitus. 45 Trigeminal neuralgia. 322–326 Thyroidectomy. 128–129 Tympanoplasty. 195. 177 Temporal bone fracture. 99 Thudicum speculum. 1 Vestibulo-ocular reflex. 309 Vidian neurectomy. 347 function tests. 320–321 Thyroid stimulating hormone (TSH). 46–48. 240 Vocal cord palsy. 172 Tullio phenomena. 350–353 nerve section. 168 schwannoma. 234 Submandibular abscess. 218–219 Temporary threshold shift. 133 Visual reinforcement audiometry. 354 Waldeyer’s ring. 47 Wegener’s granulomatosis. 354–356 Voice tests. 82 Tympanometry. 333–335 Tonsil diseases. 351–352 Vestibulo-spinal reflex. 344–345 Ultrasound. 341–343 combined approach. 267 Squamous cell carcinoma. 311. 330 Warthin’s tumour. 352 Uvulo-pharyngo-palatoplasty (UVPP/UPPP).

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